Initial Consultation Form

Patient Information

Name (First/Last/MI):
DOB:
Sex:
Email:
Address
City
State
Zip Code
Phone (C)
Phone (W)
Phone (H)
Can we call you at work? YesNo
Occupation
Employer
Marital Status SingleMarriedDivorcedWidowedSeparatedMinor

Emergency Contact

Name
Relationship
Phone
How did you hear about our practice?
Who is your Primary Physician?
Office Phone

Accident Information

Is this visit due to an accident? YesNo
If yes, what type? AutoWorkOther
Has it been reported? YesNo
If yes, to whom?

Insurance Information

Do you have health insurance? YesNo
Name of Carrier
Do you have secondary insurance? YesNo
Name of Carrier
Policy Holder Name
DOB:
Relationship to patient (if other than self)
Phone

Main Complaints: (List in priority to you.)

1)
3)
2)
4)
How long have you suffered with the primary problem?
Any other complaints

Would you like improvement with any of the following? Please check all that apply.

Digestion: Reflux, Gas, ConstipationSleep: Falling asleep or staying asleepSense of Well BeingEnergy
What have you tried doing to resolve this problem that Did Not work?
Have you become discouraged or stressed about handling this problem? If Yes, please explain.
When your problem is at its worst, how does it make you feel?
What areas in your life is this problem(s) interfering with? Please check all that apply
WorkSleepWalkingSittingStandingEmotionalRelationshipsSocial LifeSexuallyHobbies/RecreationBending/Stretching

Other

When it’s at it’s worst, how much older does this make you feel?
Do you know how this problem may have started?
What effect does this have on your body functions?
Are you here visiting us to
Resolve my immediate problemsLife style program for optimized livingBoth

Other

How have you taken care of your health in the past? Please check all that apply
MedicationsExerciseDiet and NutritionRoutine medicalVitaminsHolisticAcupuncture/PT/Chiro

Other

How did the previous methods work for you?
What are you afraid this might be or will be affecting without change? Please check all that apply
JobKidsMarriageSleepFreedomFuture abilitiesFinancesTime
Are there any health conditions you are afraid this might turn into? Please check all that apply
Diminish Future abilitiesSurgeryStressArthritisWeight gainCancerHeart diseaseDiabetesDepression

Other

Where do you picture yourself being in the next 3-5 years if this problem is not taken care of? Please be specific
What is your expectation(s) of us?
What would be different or better without this problem? Please check all that apply
Diminished StressMore EnergySelf-EsteemConfidenceQuality of LifeSleepWorkOutlook on LifeFamily
Imagine yourself 3 years in the future, what progress would you need to make in order for you to be happy? (Please take your time and don’t sell yourself short! Include anything that is part of your happiness, whether health, family, work, finances, travel, marriage or bucket list)
What potential barriers do you foresee that would prevent these things from happening?
Do you feel it is possible to eliminate or prevent these potential barriers?
What are your strengths that will enable you to accomplish your goals?

Rate on a scale of 1-10

How important is it for you to resolve your health concerns?
Do you feel that you are coachable and would enjoy a mentor in helping you?
Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?

Medical History

GASTROINTESTINAL

ConstipationDiarrheaNausea/VomitingStomach Pain/CrampingBloatingGasIrritable Bowel SyndromeInflammatory Bowel DiseaseChron’s DiseaseUlcerative ColitisGastric/Peptic UlcerGERD (reflux/heartburn)Celiac’s Disease

Other

CARDIOVASCULAR

PalpitationsHeart AttackOther Heart DiseaseStrokeChest PainSwelling of hand/feetElevated CholesterolIrregular Heart RateHypertensionHemodynamic InstabilityRheumatic FeverMitral Valve Prolapse

Other

RESPIRATORY

AsthmaChronic SinusitisBronchitisReoccurring Resp. InfectionChest CongestionWheezingShortness of BreathEmphysemaPneumoniaTuberculosisSleep ApneaCOPD

Other

METABOLIC / ENDOCRINE

Type 1 DiabetesType 2 DiabetesHypoglycemiaMetabolic SyndromeInsulin ResistancePre-DiabetesHypothyroidismHyperthyroidismEndocrine DisorderPCOSInfertilityWeight GainWeight LossInability to Lose WeightBulimiaAnorexia

Other

GENITAL AND URINARY SYSTEMS

Frequent UrinationPainful UrinationBlood in UrineCloudy UrineKidney StonesGoutInterstitial CystitisFrequent UTI’sFrequent Yeast Infections

Other

MUSCULOSKELETAL

ArthritisMuscle PainFibromyalgiaScoliosisBulging/Herniated DiscNeck PainMid Back PainLow Back PainBroken BonesJoint PainChronic Pain

Other

NEUROLOGICAL / MOOD

DepressionAnxietyIrritabilityConfusionFatigueStressBipolar DisorderSchizophreniaHeadachesMigrainesADD/ADHDAutismMild Cognitive ImpairmentMemory ProblemsParkinson’s DiseaseMultiple SclerosisAlzheimer’sSeizures

Other

INFLAMMATORY / AUTOIMMUNE

Chronic Fatigue SyndromeAutoimmune DiseaseRheumatoid ArthritisLupus SLEImmune Deficiency DiseaseSclerodermaHashimoto’s ThyroiditisMultiple SclerosisSjögren's syndromeFrequent InfectionsEnvironmental AllergiesFood AllergiesChemical SensitivityLyme’s Disease

Other

SKIN DISORDERS

EczemaPsoriasisRashesAcneDermatitisNumbness/TinglingShinglesEasy BruisingThinning HairHair LossBrittle Nails

Other

CANCER

Lung CancerBreast CancerColon CancerOvarian CancerProstate CancerSkin CancerLeukemiaLymphoma

Other

BLOOD DISORDERS

AnemiaPlatelet DysfunctionThrombocytopeniaSepticemia

SPECIFIC FOOD/DRUG/CHEMICAL ALLERGIES

Foods

Drugs

Chemicals

Other

ADDITIONAL SYMPTOMS

Feel HotFeel ColdChillsFeverHeat IntoleranceCold IntoleranceExcess SweatingNight SweatingSpontaneous SweatThirstExcess HungerPoor AppetiteInsomniaExcess DreamingWakes FrequentlyNightmaresDizziness

Cravings

Women Only Health History

OBSTETRIC HISTORY
Pregnancy
C-Section

Gestational Diabetes

 

Miscarriage
Abortion
Preeclampsia
Post Partum Depression
Toxemia
Premature Birth
Breast Feeding

Vaginal Delivery
MENSTRUAL HISTORY

Age of First Period

Frequency

Length

Painful YesNo

Clotting

Missed Period?

How Long?

Last Period

Hormone Contraceptive

Type

How Long?

WOMEN’S DISORDERS / HORMONES

Fibrocystic Breasts

Last Mammogram

Breast Biopsy/Date

Endometriosis

Uterine Fibroids

Painful Periods

Cysts

Heavy Periods

PMS

Last PAP Test

NormalAbnormal

Menopause

Vaginal Dryness

Hot Flashes

Mood Swings

Decreased Libido

Hormone Replacement

How Long?

Type?

Mens Only Health History

HORMONES / SEXUAL HEALTH

Low TestosteroneProstate EnlargementProstate InfectionDecreased LibidoImpotenceDifficult obtaining erectionDifficult maintaining erectionNocturia (urination at night)Loss of urinary controlUrgency in UrinatingHesitancy in Urinating

Have you had a PSA done? YesNo

Date

What was PSA level?

Treatment History

PREVENTATIVE TEST AND DATE OF LAST TEST

Full Physical Exam

Blood Labs

Bone Density

Colonoscopy

Cardiac Stress Test

EBT Heart Scan

EKG

Stool Test

MRI / CT Scan

Upper Endoscopy

Upper GI Series

Ultrasound

Other

SURGERIES AND DATE

Appendectomy

Hysterectomy

Ovaries

Gall Bladder

Hernia

Tonsillectomy

Thyroidectomy

Joint Replacement

Heart / Bypass

Angioplast

Pacemaker

Other

Personal Habits

ACTIVITY
Do you exercise?

NeverDailyWeekly

What type of exercise do you participate in?

WalksRunsBikingSwimmingWeightsYoga

Others

Do your work activities mainly involve?

SittingStandingLight LaborHeavy Labor

HABITS

What is your daily/weekly intake of the following?

Caffeine cups/day

Do you use recreational drugs? YesNo

Alcohol drinks/week

Type

Cigarettes packs/day

Frequency

Family Health History

IS THERE A FAMILY HISTORY OF ANY OF THE FOLLOWING CONDITION?

Please indicate the family member including parent, grandparents & siblings

Heart Disease

Hypertension

Diabetes

Stroke

Thyroid Problem

Arthritis

Cancer

HOSPITALIZATIONS
Date Reason
MEDICATIONS
Name Dosage Frequency Start Date (Month/Year) Reason For Use
SUPPLEMENTS (Vitamins/Herbs/Homeopathy)
Name & Brand Dosage Frequency Start Date (Month/Year) Reason For Use



I certify that the above questions were answered correctly. I understand that providing incorrect information can be dangerous to my health.

Patient / Guardian Signature
Date
Provider Signature
Date