NEW PATIENT PACKET. Preferred Name: Primary Street Address: Apt #: City: State: Zip Code: Date of Birth: SS#: Age: Gender: Marital Status:

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1 NEW PATIENT PACKET Congratulations on your decision to move further on the path to optimal health! We are here to educate and support you as part of our commitment partnering with you and your primary care physician in managing your health. The following information is necessary in order for us to optimize your care. Please fill out this form as completely and as accurately as possible. General Information Name: Preferred Name: Primary Street Address: Apt #: City: State: Zip Code: Date of Birth: _SS#: Age: Gender: Marital Status: Ethnicity: Race: Preferred Language: Home Phone: Work Phone: Mobile Phone: Address: Can we send you our monthly newsletter & speaking engagement invites? Preferred way to reach you: _Best time to reach you: Current Occupation: Employer: Emergency Contact Name: Phone: Relationship: Address: Apt #: City: State: Zip Code: Current Primary Care Physician Name: Phone: City: _State: Zip Code: How did you hear about us?: 1

2 Health Goals Please describe the top three (3) symptoms/conditions you seek to improve at our office (in order of importance). Please provide a brief timeline or review of the contributing factors as you see it. Problem #1 Problem #2 Problem #3 Medical Care History Check box if yes and provide dates Preventive Test Full Physical Exam Bone Density Colonoscopy Cardiac Stress Test EKG Hemoccult (stool test for blood) Mammogram Pap Smear PSA Surgical History Appendectomy Hysterectomy Ovaries removed: Yes Right / Left / Both NO Gallbladder Hernia Tonsillectomy Joint Replacement: Knee / Hip Heart Surgery: Type Angioplasty or Stent Pacemaker Date Date 2

3 Hospitalizations Date Reason For Hospitalization Specialist Care (Please list all physicians that manage your care.) Physician Name Medical Specialty Issue(s) Being Managed 3

4 Medical Symptom Questionnaire Rate each of the following symptoms based upon your typical health profile FOR THE PAST 30 DAYS. (If you are dealing with more than one symptom listed below then please rate all that apply.) Please use the scale shown below to describe the severity of your symptom and total each section. 0 Never or almost never have the symptom 3 Frequently have it, effect is not severe 1 Occasionally have it, effect is not severe 4 Frequently have it, effect is severe 2 Occasionally have it, effect is severe HEAD Headaches DIGESTIVE TRACT Nausea, Vomiting Dizziness/Faintness Diarrhea, Loose Stools Insomnia Constipation, hard/infrequent stools Bloated feeling Belching, passing gas, burping EYES Watery or itchy eyes Heartburn/acid taste in mouth Swollen, reddened or sticky eyelids Intestinal/stomach pain Dark circles under eyes Vision problems excluding near or far sighted JOINTS/MUSCLE Pain or aches in joints/arthritis Warm, swollen joints EARS Itchy ears Stiffness or limitation of movement Frequent ear infections Pain or aches in muscles Popping of ears Muscle weakness Ringing in ears WEIGHT Excessive eating/drinking NOSE Stuffy nose/excessive mucus formation Excessive craving certain foods Sinus problems Overweight/Obese Hay fever/sneezing attacks Difficulty losing weight Nose bleeding ENERGY/ACTIVITY Fatigue from mental exhaustion MOUTH Gagging, frequent need to clear throat Fatigue from emotional exhaustion Sore throat, hoarseness, loss of voice Hyperactivity (mind or body) Swollen/Discolored tongue, gums, lips Restlessness (mind or body) Canker sores MIND Poor memory SKIN Acne Confusion, poor comprehension Hives, rashes, dry skin Poor concentration Hair loss Poor physical coordination Excessive hair growth Difficulty making decisions Excessive sweating/body odor Speech difficulty Flushing, hot flashes Learning disabilities HEART Irregular or skipped heartbeat EMOTIONS Mood swings Rapid or pounding heartbeat Anxiety, fear, nervousness Chest pain Anger, irritability, aggressiveness Depression/Sadness Obsessive, compulsive behaviors LUNGS Chest congestion Asthma, frequent bronchitis Difficulty breathing OTHER Frequent illness Frequent coughing Frequent or urgent urination Genital itch or discharge 4

5 SUM OF ALL SECTIONS ABOVE: Lifestyle Information Stress/Coping Have you ever sought counseling? YES or NO Do you feel you have an excessive amount of stres in your life? YES or NO Do you feel you can manage the stress in your life? YES or NO Do yo feel you make unhealthy choices due to high stress? YES or NO Daily Stressors (Rate on a scale of =lowest; 10=highest) Work Family Social Finances Health Do you practice meditation or relaxation techniques? YES or NO Circle all that apply: YOGA MEDITATION BREATHING TAI CHI PRAYER OTHER Sleep/Rest How likely are you to doze off or fall asleep in the following situations using the scale below? 0 = Would never doze 2 = Moderate chance of dozing 1 = Slight chance of dozing 3 = High chance of dozing (Circle the answer that corresponds with above) Sitting and reading Watching television Sitting inactive in a public place (ex: a theater or meeting) Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic As a passenger in a car for an hour without a break Average number of hours you sleep per night? > <6 Do you have trouble falling asleep at night? YES or NO If yes, how long does it usually take to fall asleep? Do you have trouble staying asleep at night? YES or NO If yes, how long are your awake throughout the night? How many times do you awaken throught the night? 5

6 Please list any sleep aids (prescription or natural) and any other methods tried: Readiness Assessment Rate the following on a scale = very willing; 1= not willing (Circle appropriate answer) In order to improve your health, how willing are you to: Educate yourself on your condition Significantly modify your diet Modify your lifestyle (work demands, sleep, etc.) Practice a relaxation technique Take several nutritional supplements each day Engage in regular exercise Have periodic lab tests to assess your progress Comments Lifestyle Information Current smoker YES or NO How many years? Packs per day: Attempts to quit: Method? Previous smoker YES or NO How many years? Packs per day: Quit date:_ 2 nd hand smoke exposure NONE LOW MEDIUM HIGH How many drinks currently per week? (1 drink = 5 oz wine, 12 oz beer, 1.5 oz liquor) NONE >10 When do you drink? THROUGHOUT THE WEEK WEEKENDS MOSTLY How frequently do you drink? > 1 drink per day for females >2 drinks per day for males Previous alcohol intake? NONE MILD MODERATE HIGH Do you ever feel guilty about your alcohol consumption? YES or NO Do you notice a tolerance to alcohol (you can hold more than others)? YES or NO Do you notice you feel your alcohol at very low amounts? YES or NO Do you drink caffeine products? YES or NO Coffee Tea (Herbal or Non-Herbal) 6

7 Caffeinated or Diet Beverages per day NONE ONE TWO THREE >FOUR List favorite type (e.g. Diet Coke, Pepsi, Red Bull, Monster, etc.) Do you often take caffeine to avoid fatigue YES or NO Current Exercise Program: Activity (list type, number of sessins/week, and duration of activity) Activity Type Frequency/Week Duration in Minutes Stretching Cardio/Aerobics Strength Yoga/Pilates Sports/Leisure Activities (golf, tennis, rollerblading, etc.) Do you feel unusually fatigued after exercise? YES or NO If yes, please describe Do you usually sweat when exercising? YES or NO Digestive/Dietary History Please describe your typical daily diet by indicating your usual daily servings: Vegetables _ Dairy Fruits _ Potatoes Beans _ Fats/Oil Nuts/Seeds _ Fast Food Whole Grains _ Refined Grains Animal Protein _ Processsed Food Overall do you feel that you eat (check all that apply) too much too little just enough very healthy a little unhealthy unhealthy Do you feel like you digest you food well? YES or NO Do you feel bloated after meals? YES or NO If yes, within 30 min after eating after 1-2 hours of eating Were there years where you took more than 3 courses of antibiotics per year? YES or NO Do you experience frequent yeast infections or toe fungal infections/athlete s foot? YES or NO Are there some foods to which you are allergic, intolerant or just seem to bother you? YES or NO If yes, explain Do you suffer from alleries? Enviornmental YES or NO Food YES or NO Seasonal YES or NO 7

8 All year long YES or NO Do you ever find blood in your stool? YES or NO How many bowel movements do you have in a typical day? If your answer is less than 1 per day, how often do you have a bowel movemnt? EVERY DAYS Describe your typical bowel movement (check all that apply) Hard Soft Alternating diarrhea/constipation Pellet-Like Loose Mucus in stool Watery Complete Requires Straining Strange Color/Odor If you experience any digestive issues, when did they begin? Have you ever been referred to a Gastroenterologist? YES or NO Explain Female History Obstetric History (Provide the number of times) Pregnancies Cesarean Vaginal Deliveries Miscarriage Abortion Living Children Toxemia Baby over 8lbs Postpartum Depression Breastfeeding If breastfed children, for how long each time Age of first menstrual period: Menses Frequency_days Menses length days Describe your current menstual cycle: REGULAR IRREGULAR ABSENT Details: Last menstrual perios: Date of last PAP: Have you ever had an abnormal PAP? YES or NO If yes, date of abnormal PAP Current contraception? Total years of hormonal contraception use? Women s Disorders/Hormonal Imbalances (check all that apply) Fibrocystic Breasts Endometriosis Fibroids Infertility Painful Periods Heavy Periods PMS Are you in Menopause (no menses in last 12 months)? YES or NO If yes, NATURAL or SURGICAL REMOVAL OF OVARIES Do you currently use hormone replacement therapy? YES or NO If yes, how long? Traditional Prescription If yes, how long? Bioidentical Hormone Replacement Therapy Have you ever used hormone replacement therapy? YES or NO If yes, how long? Traditional Prescription If yes, how long? Bioidentical Hormone Replacement Therapy 8

9 Check all menopausal symptoms that apply to you: Hot Flashes Mood Swings Night Sweats Concentration/Memory Palpitations Sleep Problems Weight Gain Postmenopausal Bleeding Headaches Vaginal Dryness Medication History (attach separate page as needed) Current Medications Medication Strength Dosing Schedule Month/Yr Started Reason for Use Previous Medications Medication Strength Dosing Schedule Month/Yr Started Reason for Use Current Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy) Medication Strength Dosing Schedule Month/Yr Started Reason for Use Allergies (Environmental, Food & Drugs) Allergen Associated Symptoms Treatment needed 9

10 Genetic Risk Analysis Please place age at diagnosis where appropriate. For multiple siblings/children, place multiple checks. Mother Father Brother(s) Sister(s) Child(ren) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt(s) Uncle(s) Age (if still alive) Age at death Colon Cancer Breast Cancer Cancer Type Heart Disease Stroke Hypertension Obesity/Overweight Diabetes High Cholesterol Arthritis (<60 years old) Multiple Sclerosis Rheumatoid Arthritis/Lupus/Psoriasis Ulcerative Colitis/Crohn s Disease Irritable Bowel Syndrome Celiac Disease Asthma/Chronic Bronchitis Eczema/Hives Food Allergies or Sensitivities Environmental Sensitivities Multiple Chemical Sensitivities Dementia or Parkinson s Substance Abuse (alcoholism, drugs) Depression Anxiety ADHD Autism 10

11 Thyroid Disorders Medical History (Check appropriate box and provide date of onset. PC=Past Condition; OC=Ongoing Condition) PC OC Gastrointestinal Date of Irritable bowel Syndrome Crohn s Disease Ulcerative Colitis Gastritis or Peptic Ulcer GERD (Acid Reflux) Celiac Disease PC OC Cardiovascular Date of PC OC Genital & Urinary Systems Date of Kidney Stones Interstitial Cystitis Frequent Urinary Tract Infections Frequent Yeast Infections Erectile or Sexual Dysfunction Urinary Incontinence PC OC Musculoskeletal/Pain Date of Heart Attack Osteoarthritis Poor Circulation Fibromyalgia Stroke Gout High Cholesterol Chronic Pain Syndrome Arrhythmia (irregular beat) PC OC Inflammatory/Autoimmune Date of Hypertension (high blood pressure) Chronic Fatigue Syndrome Heart Valve Disease Autoimmune Disease Rheumatoid Arthritis PC OC Metabolic/Endocrine Date of Hashimoto s Thyroiditis Type 1 Diabetes Psoriasis Type 2 Diabetes Food Allergies Hypoglycemia (low blood sugar) Environmental Allergies Metabolic Syndrome Multiple Chemical Sensitivities Insulin Resistance or Pre-diabetes Obesity/Overweight PC OC Respiratory Diseases Date of Polycystic Ovarian Syndrome (PCOS) Asthma Infertility Chronic Sinusitis Bronchitis PC OC Neurologic/Psychiatric Date of COPD or Emphysema Depression Pneumonia Anxiety Sleep Apnea Bipolar Disorder Headaches PC OC Skin Diseases Date of Migraines Eczema ADD/ADHD Vitiligo Autism Acne Multiple Sclerosis Seizures PC OC Cancer Date of Eating Disorder (Anorexia/Bulimia) Lung Cancer Breast Cancer 11

12 Colon Cancer Ovarian Cancer Prostate Cancer Skin Cancer Food & Lifestyle Journal Please complete your Diet & Exercise Log every day. 1. Make note of the time you wake up. 2. List and describe in detail all foods and drinks, including the amount of each. Be sure to list everything. Including condiments used (e.g. mayonnaise, mustard, relish). Make note as to whether the food was fresh, frozen, canned, raw, cooked, baked, fried, etc. 3. Note the time of each meal or snack. 4. Include any strong feelings, symptoms or changes in energy that may arise either between meals or relative to foods you are consuming (e.g. happiness, sadness, anger, indigestion, fatigue). 5. Keep track of how much water you drink and list the amount in ounces (or ml) in the section provided. Also note the type and amount of any other drinks you consume. 6. Write down any activity or exercise you do, listing the kind of exercise you did and for how long you exercised. 7. Note any periods of relaxation and what kind of relaxation it was. 8. Note the time you go to sleep. Notes: 12

13 DAY 1 Wake up time: Morning meal time: Morning snack time: Midday meal time: Afternoon snack time: Evening meal time: Evening snack time: Water/Drinks (not listed with meals above): Activity/Exercise (detail type and duration): 13

14 Relaxation/Sleep (detail type and duration): Wake up time: DAY 2 Morning meal time: Morning snack time: Midday meal time: Afternoon snack time: Evening meal time: Evening snack time: Water/Drinks (not listed with meals above): Activity/Exercise (detail type and duration): 14

15 Relaxation/Sleep (detail type and duration): Wake up time: DAY 3 Morning meal time: Morning snack time: Midday meal time: Afternoon snack time: Evening meal time: Evening snack time: Water/Drinks (not listed with meals above): Activity/Exercise (detail type and duration): 15

16 Relaxation/Sleep (detail type and duration): 16