Integrative Medicine New Patient Packet
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- Annis Rich
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1 General Information Integrative Medicine New Patient Packet Please fill out this form as completely and as accurately as possible. 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?: Revised: April 2,
2 Health Goals Please list your top 3 health goals. Problem #1 Problem #2 Problem #3 Medical Care History Check box if yes and provide dates Preventive Test Full Physical Exam Mammogram Pap Smear PSA Colonoscopy Surgical History Hysterectomy Ovaries removed: Yes Right / Left / Both NO Gallbladder Joint Replacement: Knee / Hip Heart Surgery: Type Pacemaker Any other hospitalizations? Date Date Revised: April 2,
3 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 SUM OF ALL SECTIONS ABOVE: Revised: April 2,
4 Lifestyle Information Stress/Coping Do you feel you have an excessive amount of stress in your life? YES or NO Do you feel you can manage the stress in your life? YES or NO Do you practice meditation or relaxation techniques? YES or NO Sleep/Rest Average number of hours you sleep per night? > <6 Do you have trouble falling asleep at night? YES or NO Do you have trouble staying asleep at night? YES or NO Please list any sleep aids (prescription or natural) and any other methods tried: Social Current smoker YES or NO Vaping YES or NO Previous smoker YES or NO Cannabis YES or NO How many drinks currently per week? NONE >10 When do you drink? THROUGHOUT THE WEEK WEEKENDS MOSTLY How many caffeinated products do you drink per day? Coffee Tea Soda Energy Drinks Do you feel like you re more sensitive to chemicals than other people are? YES or NO If yes, explain Revised: April 2,
5 Current Exercise Program Activity (list type, number of sessions/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 usually sweat when exercising? YES or NO Do you feel unusually fatigued after exercise? YES or NO If yes, please describe Digestive/Dietary History Overall do you feel that you eat (check all that apply) too much very healthy too little a little unhealthy just enough unhealthy Do you feel like you digest your food well? YES or NO Do you feel bloated after meals? YES or NO 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 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 to a Gastroenterologist? YES or NO Explain Revised: April 2,
6 Male History Do you frequently wake at night to urinate? YES or NO Are you currently taking male hormone replacement therapy? YES or NO If yes, what are you taking? Are you requesting male hormone replacement therapy? YES or NO Female History Obstetric History (Provide the number of times) Pregnancies Deliveries Miscarriages Are you pre-menopausal? If yes, fill out below. If no, skip to menopause section. Menses Frequency_days Menses length days Describe your current menstual cycle: REGULAR IRREGULAR ABSENT Details: Last menstrual period: 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 Menopause 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 Please check all menopausal symptoms that currently apply to you: Hot Flashes Mood Swings Night Sweats Concentration/Memory Palpitations Sleep Problems Weight Gain Postmenopausal Bleeding Headaches Vaginal Dryness Revised: April 2,
7 Medication History (attach separate page as needed) ***Please bring in all of your supplements and medications to your visit*** 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 Revised: April 2,
8 Mother Father Brother(s) Sister(s) Child(ren) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt(s) Uncle(s) Genetic Risk Analysis Please place age at diagnosis where appropriate. For multiple siblings/children, place multiple checks. 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 Thyroid Disorders Revised: April 2,
9 Personal 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 Colon Cancer Ovarian Cancer Prostate Cancer Skin Cancer Revised: April 2,
10 Wake up time: Write down everything you eat and drink for 3 days. DAY 1 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): Relaxation/Sleep (detail type and duration): Revised: April 2,
11 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): Relaxation/Sleep (detail type and duration): Revised: April 2,
12 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): Relaxation/Sleep (detail type and duration): Revised: April 2,
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