OM Integrative Infusion Center

Transcription

1 OM Integrative Infusion Center Patient Demographic Form Today s Date Patient Information Patient Name: Date of Birth(DOB): / / Age: Social Security Number: / / Sex: M F Marital Status: Single Married Widow/er Divorced Partner Mailing Adress: Street with house number City State Zip code Physical address (if not the same as paling address): Street City State Zip code Home Phone: ( ) - Cell/pager ( ) - May we leave a message? Y N May we contact you via ? Y N Address: Patient Employer: Occupation: Full/part time Address: Work phone ( ) - Emergency Contact: DOB / / Work #: ( ) - Address: Social Security #: - - Guarantor/Parent Information (if applicable) Responsible Party Name: DOB: / / SS# Address: Home phone: ( ) - Employer: Work phone: ( ) - Relationship to patient: Cell/Pager #: ( ) - Patient Referral Information Referred by (circle or complete) Family, Friend, Hospital, Health care provider Primary Care Provider Referring Provider PLEASE read and sign I understand that I am responsible for all charges incurred on my behalf. All services at this center are not covered by all types of Insurance and are to be paid on the date of services rendered. Patient/responsible party: Date

2 Health History Name Today s Date Age Height Weight gain or loss in the last year Gender M F # of children Allergies Reason for the clinic visit: Date this began Date of last physical Exam Practitioner name and phone # Laboratory performed (Ex. Stool analysis, blood, urine, chemistries, hair) Outcome What types of therapy have you tried for this problem(s): Underline all that apply: Diet modification Fasting Vitamins/minerals Herbs Homeopathy Chiropractic Acupuncture Conventional medications Other List current health problems for which you are being treated: Current medications (prescription or over-the counter): Major hospitalizations, surgeries, injuries: Please list all procedures, complications, and dates: Year Surgery, illness, injury Outcome Rate the level of stress that you are experiencing on a scale of 1 (lowest) to 10 (highest) Identify what is your major cause of stress: (job change, work, home, finances, legal issues Is your job associated with potentially harmful chemicals (ex. pesticides, radioactivity, solvents) or health/life threatening activities (fireman, farmer, miner). Explain Do you have: Corrective lenses Dentures Hearing Aides other implanted medical devices Recent changes in your ability to: See, hear, taste, smell, feel hot/cold sensations, move around as you had before. Please explain Strong desire for any of the following flavors: sour, bitter, sweet, rich/fatty, spicy/pungent, salty Strong dislike for any of the following flavors: sour, bitter, sweet, rich/fatty, spicy/pungent, salty Do you: prefer warmth (Ex. Food, drinks, weather, etc.) Prefer cold (Ex. Food, drinks, weather, etc. Is your sleep disturbed at the time each night? If yes, what time? Time of day you feel the least symptoms: Time of day you feel the worst symptoms: 7-9AM 9-11AM 11AM PM 7-9AM 9-11AM 11AM - 1PM 1-3 PM 3-5 PM 5-7 PM 7-9 PM 9-11 PM 3-5 PM 5-7PM 7-9 PM 9-11PM 11 PM - 1 AM 1-3 AM 3-5 AM 5-7 AM 11 PM - 1 AM 1-3 AM 3-5 AM 5-7 AM Do you experience any of these general symptoms EVERY DAY? Debilitating fatigue Shortness of breath Insomnia Constipation Chronic pain/inflammation Depression Panic Attacks Nausea Bleeding Fecal Incontinence No interest in sex Headaches Vomiting Discharge Urinary Incontinence No interest in eating Dizziness Diarrhea Itching/rash Low grade fever Stool Frequency: # of Stools/per day Other

3 MEDICAL HISTORY (x all that apply) Arthritis Allergy/Hay Fever Asthma Alcoholism Autoimmune Disease Blood pressure problems Bronchitis Cancer Chronic Fatigue Carpal Tunnel High Cholesterol Circulatory issues Colitis Dental Problems Depression Diabetes Diverticular Disease Drug Addiction Eating Disorder Epilepsy Emphysema Eyes, ears, nose, throat issues Environmentally sensitive Fibromyalgia Food Intolerance Gastroesophageal Reflux Disease Genetic Disorder Glaucoma Gout Heart Disease Chronic Infection Inflammatory Bowel Disease Irritable Bowel Syndrome Kidney or Bladder Disease Learning Disabilities Liver/gall bladder Disease Mental Illness Intellectual Disability Migraine headaches Neurologic problems(parkinsons) Sinus Problems Stroke Thyroid problems Obesity Osteoporosis Pneumonia Sexually Transmitted Disease Seasonal Affective Skin problems Tuberculosis Ulcer Urinary Tract Infection Varicose Veins Open wounds Male Concerns (x all that apply) Prostate Problems (BPH, etc.) Prostate Cancer Decreased Sex Drive Infertility Sexually Transmitted Disease Other Female Concerns (x all that apply) Menstraul Irregularities Endometriosis Infertility Fibrocystic Breast Disease Fibroid/Ovarian Cysts Premenstrual Syndrome Breast Cancer Pelvic Inflammatory Disease Vaginal Infections Decreased Sex Drive Sexually Transmitted Diease Other Age of first period Date of last gynecological exam Mammogram + - PAP + - Form of birth control # of children # of pregnancies births by C-section Surgical Menopause Date of last menstrual cycle Length of cycle days # of days between cycles Any recent changes in normal menstrual flow (Ex. Heavier, large clots, scanty) Family Health History (Parents and Siblings) x all that apply Arthritis Asthma Alcoholism Alzheimer s Disease Cancer Depression Diabetes Drug Addiction Eating Disorder Genetic Disorder Glaucoma Heart Disease Infertility Learning Disabilities Mental Illness Intellectual Disability Migraine Headaches Neurologic Disorders Obesity Osteoporosis (Parkinson s, Paralysis) Stoke Suicide

4 Health Habits Tobacco Cigarettes/day # Cigars #/day What type of water: tap filtered Other # oz./day Alcohol Wine # of glasses/day or week Beers #/ day or week Liquor oz./day or week Caffeine Coffee, # cups/day Tea, # cups/day Soda w/ caffeine, # oz./day Other Exercise (x all that apply) 5-7 days/week 3-4 days/week 1-2 days/week 45 minutes or more duration per workout minutes duration per workout Less than 30 minutes Walk Run, jog, jump rope Weight lift Swim Box Yoga Cross Train Nutrition, Diet and Food Frequency (x all that apply) Mixed food diet Vegetarian Vegan (Animal and Vegetable sources) Salt Restriction Fat Restriction Reduce Starch/ Carbohydrates The Zone Diet Restrict Total Calories Check (x) Specific Food Restrictions: Dairy Wheat Eggs Soy Corn All Gluten. Other Servings per Day: Fruits (citrus, melons, etc.) Grains (unprocessed) Dark greens or deep yellow/orange vegetables Beans, Peas, Legumes Dairy, eggs Meat, poultry, fish Eating Habits Skip breakfast Two meals/day One meal/day Graze Food Rotation Add salt to food Eat constantly whether hungry or not Eat on the run Current Supplements (x all that apply) Multivitamin/Minerals Vitamin C Vitamin E EPA/DHA Evening Primrose/GLA Calcium, source Magnesium Zinc Probiotics Minerals (list) Digestive Enzymes Amino Acids CoQ10 Antioxidants Herbs - teas Chinese Herbs Ayurevedic herbs Homeopathy Bach Flowers Protein shakes Liquid Meals Superfoods ( Ex. bee pollen, phytonutrient blends, etc.) What would you hope to achieve: (x all that apply) Have more energy Be stronger More endurance Increase sex drive Be thinner Be more muscular Improve complexion Stronger nails Healthier hair Be less moody Be less depressed Be less indecisive Feel more motivated Be more organized Improve memory Be able to think more clearly/focused Be able to test better Be free of pain Stop use of over-the-counter medications Sleep better Have agreeable breath Have agreeable body odor Have stronger teeth Get less colds/flu Get rid of allergies Reduce risk of inherited disease, List Name three things in this life that are most important to you: 1. Thank you for your time. We look forward 2. to partnering with you in your quest for 3. wellness.

5 Cancellation and No Show Policy Our goal is to provide quality care in a timely manner. In order to do so, we have found it necessary to implement a cancellation and no show policy. This policy enables us to better utilize our available appointments, facilities and clinical resources to serve those patients in need of care and our services. Cancellation of Appointment If it is necessary to cancel your appointment, we require that you call in and contact us 24 hours prior to your scheduled appointment. Appointments are in high demand and your early cancellation will give another person the opportunity to have access to our care. How to Cancel Your Appointment To cancel an appointment, please call during normal business hours, or leave a message if after hours. Cancellations by contacting anyone in the office personally, by written or voic , will not be honored. Regular business hours for OM Integrative Infusion Center, are presently every Monday, Wednesday and Friday, unless closed in observance of a holiday. Late Cancellations Late cancellations will be considered a no show appointment, unless emergent, extenuating and verifiable circumstances exist. No Show Policy A no show appointment is when someone misses an appointment without cancelling the appointment 24 hours prior to their scheduled appointment, as disclosed above. Failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a no show. In addition, there will be a $50 fee/per no show appointment applied to the patient s file. Repeated no show appointments could result in discharge from our practice. I have read and understand the above Cancellation and No Show Policy. Patient Name Date Patient Signature New Patient - Rev. 5/2017