REGISTRATION FORM. PATIENT INFORMATION Name Phone Number (s) Date of Birth Primary. Alternate Address City State, Zip Code

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1 Gemie M. McLeod, NMD Licensed Naturopathic Medical Doctor 820 Ainsworth Drive, Suite B Prescott, AZ Office Fax info@innatewellnessaz.com innatewellnessaz.com REGISTRATION FORM PATIENT INFORMATION Name Phone Number (s) Date of Birth Primary Alternate Address City State, Zip Code Occupation Employer Employer Phone Number Marital Status (circle one) Address How did you hear about us? Single/ Mar/ Div/ Sep/ Wid CONTACT METHODS It may be valuable or necessary for this office or your doctor to contact you via phone or . If you provided an address to our office, reminder s regarding upcoming appointments will be sent. Please choose the following options regarding other means of contact: ( ) Yes, IWMC may leave me a voic related to my care at Primary or Alternate number (circle one) ( ) Yes, IWMC may me related to my care ( ) NO, I do NOT want any messages or s in addition to the automatic reminder IN CASE OF EMERGENCY Name of local relative or friend Relationship to Patient Contact Number PATIENT SIGNATURE By signing below, I am acknowledging the following: the above information is true and correct to the best of my knowledge; I am financially responsible for any balance due at the time of service; I have received and understood the Insurance Billing Policy; I have received and understood the Notice of Privacy Practices in regards to the Health Insurance Portability & Accountability Act of 1996 (HIPAA); I will receive appointment reminder s if I have provided an address above; I will abide by the office policy regarding cancellations. Patient/Guardian Signature Date 1

2 MEDICAL HISTORY How committed are you towards making valuable life changes? (circle one) LITTLE MODERATELY VERY Please list your chief concerns in order of decreasing severity, starting with the worst one: Concern/Problem Date of Onset Frequency (if applicable) Severity Please list date of last complete blood work and ordering Physician: FAMILY HISTORY Father Mother Siblings Grandparents Spouse Children Age (if living) Age at death & cause Cancer/type Hypertension Heart Attack Stroke Heart Disease Asthma/Allergies Mental Illness 2

3 Tuberculosis Auto-Immune Disorder Diabetes/Type List all surgeries and hospitalizations with date: Please note when and why you have had the following: X-Rays MRI/CT Scans Ultrasounds Accidents TB Test Last Dental Visit HIV Last Eye Exam Please list current and past diagnoses, onset or diagnosis date, and treatments: Diagnosis Onset or Diagnosis Date Treatment Have you been exposed to the Disease (D), Immunization (I), or Neither (N)? Circle your response: Measles D I N Chicken Pox D I N Rubella D I N Whooping Haemophilus Tetanus D I N D I N D I N Cough (Hib) German D I N Mumps D I N Hepatitus B D I N Measles Vaccination Reactions: 3

4 Regarding use of the following, please circle Yes (Y), No (N), or Past (P): Antacids Steroids Smoking Analgesics Laxatives Coffee Soda Pop Oz./day Alcohol Alcohol Treatment Recreational Drugs Drug Addictions Packs/day & Years Cups/day Past & present How much & how often Drug Treatment When you drink caffeinated beverages, do you find it difficult to handle the effects from caffeine? List all prescription medication and nutrient supplements/herbs that you are taking and include dosage, if known. REVIEW OF SYSTEMS Present Weight: Weight one year ago: Height: Ideal Weight: Regarding the next section: If you answer YES and you have the problem now, circle Y If you answer NO, and you have never had the problem, circle N If you have had the problem in the Past, circle P Good Energy: Fatigue: If you have fatigue, when is it the worst morning, afternoon, evening (circle one) If you have fatigue, can you do what you need to during the day? Y N Circle Energy LeveL: (0= no energy 10 = most energy) SKIN Rash Color Changes Hives Lump Psoriasis/eczema Itchy Dry Warts/Moles Cancer Perspiration 4

5 HEAD Headache Migraine Dandruff Head Injury Oily/Dry Hair Hair Loss NOSE Frequent Colds Nosebleeds Congestion Post Nasal Drip Polyps Seasonal Allergies EYES Dry/Watery Blurry Vision Double Vision Cataracts Glaucoma Styes Eye Strain Discharge Itchiness Dark under Eyelids MOUTH & THROAT Canker Sores Cold Sores Sore Throat Gum Disease Root Canals Amalgam fillings Loss of Taste Hoarseness NECK Stiffness Swollen Glands Full Movement Tension RESPIRATORY Cough Tuberculosis (TB) Shortness of breath with Bronchitis exertion Shortness of breath sitting Pneumonia Shortness of breath lying Asthma down Wheezing Painful breathing CARDIOVASCULAR High Blood Pressure Rheumatic Fever Low Blood Pressure Murmurs Arrhythmia Palpitations Edema Chest Pain 5

6 URINARY TRACT Incontinence Pain with urination Frequent Infections Kidney Stones Urgency Discharge/Blood GASTROINTESTINAL Heartburn Bowel Movement Frequency: Indigestion Recent BM change Bloating Diarrhea or Constipation Nausea Hemorrhoids Vomiting Gallbladder Disease Change in appetite Liver Disease Pancreatitis Ulcer Colonoscopy Date: Please list any food allergies: FEMALE Age Menses began Frequency of Menses (i.e., every 28 days) Length of Menses in Heavy menstrual days bleeding/clots PMS Menstrual Pain Last menses date Food Cravings Last Pap Smear Times pregnant Abnormal Paps How many births Date of abnormal paps Abortions Diagnosis of abnormal pap: Vaginitis Sexually active Menopause since what age Types of Hormones used Dry Vaginal Tissue Sexually Transmitted Pain with Intercourse Infections Mammography Healthy libido If yes, list date & DEXA Scan results 6

7 List any birth controls used and ages used MUSCULOSKELETAL Weakness Arthritis Stiffness Leg Cramps Tremors Pain NERVOUS SYSTEM Paralysis Sciatica Tingling/Numbness Carpal Tunnel Syndrome Seizures Fainting MENTAL/EMOTIONAL Depression Anger/Irritability Suicidal High strung/tense Anxiety Fear/Panic Eating Disorder Psych Hospitalization History of sexual, mental/emotional, or physical abuse: Y N If so, at what age and by whom: EXERCISE How often do you exercise? What type of exercise? For how long? Hobbies: DIET Please list a typical daily dietary intake: Breakfast Lunch 7

8 Dinner Snacks Dessert Fluids SLEEP How many hours per night? If you frequently wake, what is the reason? Nightmares: Wake Refreshed: Must day nap: Sleep walk: Grind Teeth: Snore: TOXIN EXPOSURE Did you grow up near any refinery, polluted area or in a home with leaded paint? If so, what sort of pollution were you exposed to? Have you had any jobs where you were exposed to solvents, heavy metals, fumes or other toxic materials? Have you recently put new carpeting in your home, painted your home, installed new cabinets or did other refurbishing? Are you particularly sensitive to perfumes, gasoline, or other vapors? Do you use pesticides, herbicides other chemicals around your home? Please provide any additional comments or insights in the space below: What is your expectation, goal, or desire from this initial appointment with Dr. Gemie? 8

9 WHEEL OF LIFE NAME: DATE: Physical Environment (eg. Home) Career Fun, Leisure and Recreation Money 0 10 Personal Growth and Learning Health Significant Other / Romance Friends and Family WHEEL OF LIFE INSTRUCTIONS The 8 sections in the Wheel of Life represent balance. Please change, split or rename any category so that it s meaningful and represents a balanced life for you. Next, taking the center of the wheel as 0 and the outer edge as 10, rank your level of satisfaction with each area out of 10 by drawing a straight or curved line to create a new outer edge (see example) The new perimeter of the circle represents your Wheel of Life. Is it a bumpy ride? 9 8 EXAMPLE