The Gerson Institute of Ayurvedic Medicine                                                           

Jupiter Medical Center at The Calcagnini Center for Mindfulness    1210 S. Old Dixie Highway   Jupiter, Florida 33458              (Ask about our other locations in Greater West Palm Beach)      (561) 510-3833 or (561) 263-MIND

 

Scott Gerson, M.D., Ph.D. (Ayu)
The Gerson Institute of Ayurvedic Medicine
8365 Pine Cay W. Palm Beach, FL 33411
561-510-3833 This email address is being protected from spambots. You need JavaScript enabled to view it.

REGISTRATION

FIRST NAME _________________________  LAST NAME__________________ MIDDLE______

ADDRESS_______________________________________________ APT#___________

CITY ________________________ STATE____________________ ZIP_________

HOME PHONE_______________CELL PHONE _________________ WORK PHONE _______________

EMAIL ADDRESS _____________________________________________________________

__Yes, I wish to receive emails from Dr. Gerson about upcoming events __ No emails please

SS#________________________________ SEX: MALE ____     FEMALE ____

DATE OF BIRTH __________________ AGE ______________ MARITAL STATUS ____________________

REFERRED TO DR. GERSON BY ____________________________________________________________

EMPLOYER______________________________________________________________________________

EMPLOYER ADDRESS ____________________________________________________________________

INSURANCE CO. NAME ___________________________________________________________________

INSURANCE CO. ADDRESS ________________________________________________________________

INSURANCE CO. PHONE _____________________________

INSURANCE ID# ___________________________________ GROUP# ______________________________

NAME OF INSURED ___________________________________INSURED'S SS# ______________________

INSURED'S ADDRESS______________________________________________________________________

INSURED'S PHONE ___________________  YOUR RELATIONSHIP TO INSURED _____________________  

                          FULL PAYMENT IS EXPECTED AT THE TIME OF YOUR VISIT.
*ALL DIAGNOSTIC PROCEDURES WILL BE BILLED DIRECTLY TO YOUR INSURANCE COMPANY *.
ANY CANCELLATION WITHIN 24 HOURS OF THE APPOINTMENT WILL INCUR A CHARGE OF 50% OF THE OFFICE VISIT FEE.

AUTHORIZATION & ASSIGNMENT

I AUTHORIZE DR. GERSON TO FURNISH INFORMATION TO MY INSURANCE CARRIER CONCERNING MY MEDICAL TREATMENT.

I ASSIGN THE DOCTOR ALL PAYMENTS FROM MY INSURANCE COMPANY FOR ANY
MEDICAL AND/OR DIAGNOSTIC SERVICES RENDERED. I AM RESPONSIBLE FOR THE COST OF
OFFICE VISITS.


_______________________________________________ ____________________________
PATIENT'S SIGNATURE                                                     DATE

 

 

 

 

 

 

 

 

 

 

                         Scott Gerson, M.D., Ph.D. (Ayu)

MEDICAL HISTORY

 

FIRST NAME _________________________  LAST NAME__________________ MIDDLE______

ADDRESS_______________________________________________ APT#___________

CITY ________________________ STATE____________________ ZIP_________

HOME PHONE_______________CELL PHONE _________________ WORK PHONE _______________

EMAIL ADDRESS _____________________________________________________________

__Yes, I wish to receive emails from Dr. Gerson about upcoming events __ No emails please

SS#________________________________ SEX: MALE ____     FEMALE ____

DATE OF BIRTH __________________ AGE ______________ MARITAL STATUS ________________

PLACE OF BIRTH_______________________________NATIONALITY____________________________

EDUCATION____________________OCCUPATION_______________HOW LONG___________________

                 (highest level)

WHERE AND WHEN HAVE YOU LIVED OR TRAVELED OUTSIDE THE U.S._______________________            ________________________________________________________HOW LONG? __________________

FOOD/DRUG ALLERGIES______________________________________HT.__________WT.__________

CURRENT MEDICATIONS_______________________________________________________________

HOSPITALIZATIONS &/OR SURGERIES  

REASON / DATE

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 __________________________________________________________________________________

FAMILY MEDICAL HISTORY

RELATIONSHIP                                                            PROBLEM

_____________________________              _________________________________________

_____________________________              _________________________________________

_____________________________              _________________________________________             

DO YOU SMOKE? ________IN THE PAST? _______HOW LONG?______HOW MANY?______________        

DO YOU DRINK ALCOHOLIC BEVERAGES? _______HOW MUCH WEEKLY?____________________            

DO YOU DRINK COFFEE? _____________HOW MUCH DAILY? ___________________                                   

PLEASE CHECK THE FOLLOWING IF THEY APPLY TO YOU:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                 

 

The Gerson Institute of Ayurvedic Medicine

AYURVEDIC  QUESTIONNAIRE

PLEASE ANSWER THE FOLLOWING QUESTIONS IN TERMS OF YOUR PATTERN OR

TENDENCY OVER YOUR LIFETIME, NOT NECESSARILY YOUR CURRENT STATE.

 

 1. Which of the following styles most accurately describes how you perform your activities?

   a) Quickly, with a lot of enthusiasm

   b) With medium speed, intensely

   c) More slowly and methodically

 2. How easily do you become excited or enthused?

   a) Very readily

   b) Fairly quickly

   c) Not easily

 3. How easily do you become frightened?

   a) Very easily

   b) Fairly easily

   c) Not easily

 4. How quickly do you pick up new information?

   a) Very quickly, usually the first time

   b) Quite quickly

   c) More slowly, prefer to review material several times

 5. Which of the following best describes your memory?

   a) Good short-term, but tend to forget rather quickly

   b) Medium; it depends

   c) Good long term

 6. Which of the following best describes your digestion?

   a) Quite easily upset; tendency towards gas and bloating

   b) Virtually never a problem; can eat nearly everything with no discomfort

   c) Digestion is slow; stomach feels heavy long after meals

 7. Which of the following best DESCRIBES your appetite?

   a) Irregular; varied

   b) Strong; do not like to skip meal

   c) Generally do not feel strong hunger; can easily skip a meal

 8. How would you characterize your capacity for food intake?

   a) Varies a lot

   b) Can eat a lot at one time without discomfort

   c) Low

 9. Which, if any, of the following groups of tastes do you specifically prefer?

   a) Sweet, sour, salty

   b) Sweet, bitter (green, leafy vegetables) astringent (split peas, dried beans)

   c) Hot and spicy, bitter, astringent

   d) None of the above

10. How would you describe your manner of speech?

   a) Fast, talkative, unsteady, feeble

   b) Sharp, cutting, good speaker

   c) Sweet, clear, rich, booming

11. Which, if any, of the following types of foods do you crave?

   a) Warm, cooked foods and hot drinks

   b) Cold foods and drinks

   c) Dry, crunchy foods

   d) None of the above

12. Which, if any, of the following types of foods do you crave?

   a) Cold

   b) Hot

   c) Cold and damp

   d) None of the above

13. Which of the following best describes your sleep pattern?

   a) Light sleeper, frequently awakened

   b) Sound sleeper, need 6-8 hours

   c) Deep sleeper, need more than 8 hours

14. Which of the following best describes your bowel habits?

   a) Irregular, not every day

   b) More than twice daily

   c) Regular, once every day

15. Towards which of the following do you have a tendency?

   a) Hard, dry stools

   b) Loose stools

   c) Formed stools

16. How easily do you perspire?

   a) Not easily, only, only when very hot

   b) Easily, more than is comfortable

   c) Very little, ever

17. How would you describe the strength of you sexual drive?

   a) Mild

   b) Moderate

   c) Strong

18. How do you feel inside when you run into some problem or difficulty?

   a) Worried, mind moving back and forth, anxious

   b) Irritated, angry

   c) Calm, stable and clear-minded

19. Which colors do you most prefer?

   a) Blue, brown, green

   b) Violet, red, orange, yellow

   c) White

20. Which of the following book/movie themes interest you the most?

   a) Adventure, science-fiction, travel

   b) Action, combat, non-fiction                     

            c)  Romance and fantasy           

 

 

 

 

 

 

The Gerson Institute Of Ayurvedic Medicine

Scott Gerson, M.D., Ph.D. (Ayu)

                                   

 

CONSENT TO BE TREATED WITH

ALTERNATIVE MEDICAL THERAPIES

 

I,_______________________________hereby consent to be treated for my medical condition(s) with methods of treatment, which may not be considered usual or customary methods of treatment.

As with any medical treatment, I clearly understand that there is no guarantee of cure or improvement in my medical condition(s) when using these methods of treatment. I have had time to ask all pertinent questions and they have been answered to my satisfaction.

Furthermore, I understand that Scott Gerson, M.D. is not to be considered my primary physician. I agree to establish a relationship with another orthodox (non-alternative) physician who is to be my primary physician and who will have the ultimate responsibility of my medical care. I understand that I am using the services of Scott Gerson, M.D., in order to add alternative medical treatments to the usual and customary medical treatments that I have obtained or agree to obtain from my primary conventional (non-alternative) physician.

I agree to hold harmless Scott Gerson, M.D., Ayurved.M.D., The Gerson Institute of Ayurvedic Medicine, as well as any and all personnel from any present or future liability arising from any and all treatments or advice received by me at this facility at any time.

Patient Signature: ___________________________________________________Date_______________