New Patient Instructions
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- Sharyl Osborne
- 5 years ago
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1 New Patient Instructions Congratulations on your new health journey We promise to make this transition towards a healthier lifestyle a much easier one for you. In order to help you as effectively as possible please follow the below instructions. 1. Along with this form, please download and fill out the Nutritional Assessment Questionnaire form from 2. Please fill out the patient demographic and chief complaint forms to help us understand your health related goals and challenges. 3. Please fill out your list of medications and/or supplements where indicated 4. Document your diet for at least 3 days. Do not change how you eat, simply write it down. You will be asked to fill out a similar form daily as a patient moving forward. 5. Have a partner take your body measurements. Follow the instructions closely. Please call if you have any questions. 6. Please call your doctors office and have your most recent lab work and pertinent medical records faxed to our office. Our fax number is During your first appointment, you will be asked to provide a urine and saliva sample. We have provided detailed instructions on how to prepare for this appointment. Please follow these instructions closely, call if you have questions.
2 New Patient Intake Form DEMOGRAPHIC INFORMATION Name Phone# Cell# Work# Address City State Zip Code of Birth Social Security# Status: Single Married Divorced Children? Y N How many? Occupation Name of Family Doctor Phone Name of Specialist Phone Emergency Contact Phone How did you hear about us? TV Radio Friend Lecture Other CHIEF COMPLAINT / HISTORY WHAT WOULD YOU LIKE TO IMPROVE ABOUT YOUR HEALTH? What treatment have you had for these conditions? Complete this section even if you have minor aches and pains or any other problem areas (i.e. stomach) Circle the intensity of your pain (0 = no pain, 10 = worst pain) Is this due to: Poor Lifestyle? Illness? 0 1 Auto Injury? Work Injury? Unknown? Other? How long have you had this complaint? Are your symptoms: Improving? Getting Worse? Does the Pain Radiate? Yes About the same? Comes and goes? No If yes, describe: Have you had these symptoms before? Yes No Have you lost time from work? Yes No s lost returned to work When? Dr Ordered? Yes No Self determined? Yes No Effect on Activities: No Effect Extra Effort Required Occasional Limitation Severe Limitation
3 CHECK OFF ANY SYMPTOMS THAT YOU HAVE EXPERIENCED Circle the condition that bothers you the most and indicate how long you have had this/these condition(s) Headaches Fatigue Pain/Tension/Numbness Neck Shoulders Low Back Legs Arms Hands Feet Other Sleep Issues Hormone Imbalances Hot Flashes Mood Swings PMS Irritability Digestive Problems Constipation Acid Reflux IBS/Crohn s Food Sensitivities Sinus Problems/Allergies Difficult Weight Loss Arthritis Depression/Anxiety High Stress Levels High Blood Pressure Dizziness Fibromyalgia Other Other Other TELL US MORE ABOUT YOUR CURRENT HEALTH AND LIFESTYLE I currently weigh pounds I would like to lose pounds by My Waist size is inches My blood pressure is: High Low Normal? I sleep hours per night I go to bed at: and wake up at: In the morning I feel: tired refreshed My Cholesterol is: Smoking Yes No Packs/day Coffee Yes No Cups/day Soft Drinks Yes No Cans/day Alcohol No Drinks/week High Low Normal? I eat servings of fruits per day I eat servings of vegetables per day I drink ounces of water per day I exercise hours per week I exercise days per week After work I feel: tired energetic Yes I eat out times per week MEDICATIONS AND SUPPLEMENTS DRUG / VITAMIN DOSAGE REASON FOR TAKING I WOULD LIKE HELP WITH THE FOLLOWING (CHECK ALL THAT APPLY) Diet and Nutrition Lifestyle Coaching Grocery Store Tour Chiropractic Care Weight Loss Condition(s) Listed Above Exercise Program General Health and Wellness Supplements Other
4 Medical History - Please CHECK MARK current conditions and CIRCLE past conditions General Allergies Depression Dizziness Fainting Fatigue Fever Headaches Difficulty / Loss of sleep Mental illness Nervousness Tremors Weight loss / gain Major Stress Muscle / Joint Arthritis / rheumatism Bursitis Foot trouble Muscle weakness Low back pain Neck pain Mid back pain Joint pain Gastrointestinal Abdominal pain Bloody or tarry stool Colitis / Crohn s Colon trouble Constipation Diarrhea Difficult digestion Diverticulosis Bloated abdomen Excessive hunger Gallbladder trouble Hernia Hemorrhoids Intestinal worms Jaundice Liver trouble Nausea Painful defecation Pain over stomach Poor appetite Vomiting Vomiting of blood Genitourinary Bed-wetting Bladder infection Blood in urine Kidney infection Kidney stones Prostate trouble Pus in urine Stress incontinence Skin Boils Bruise easily Dryness Hives or allergies Itching Varicose veins Eye, Ear, Nose & Throat Colds Deafness Ear ache Eye pain Gum trouble Hoarseness Nasal obstruction Nose bleeds Ringing of the ears Sinus infection Sore throat Tonsillitis Vision problems Urination More than 8x in 24hrs Decreased flow/force Painful urination Urgency to urinate Cardiovascular High blood pressure Low blood pressure Hardening of the arteries Irregular pulse Pain over heart Palpitation Poor circulation Rapid heart beat Slow heart beat Swelling of ankles Women only Congested breasts Hot flashes Lumps in breast Menopause Vaginal discharge Menstrual flow Reg. Irreg Pain/cramps Days of flow: Length of cycle: - 1st day last period: Are you pregnant? yes, no If yes, how many months? How many children do you have? Birth control method: of last PAP test: normal, abnormal of last mammogram: normal, abnormal Respiratory Chest pain Chronic cough Difficulty breathing Hay fever Shortness of breath Spitting up phlegm / blood Wheezing Check any of the conditions you have or have had: Alcoholism Anemia Appendicitis Arteriosclerosis Asthma Bronchitis Cancer Chicken pox Cold sores Diabetes Eczema Edema Emphysema Epilepsy Goiter Gout Heart burn Heart disease Hepatitis Herpes High cholesterol HIV/AIDS Influenza Malaria Measles Miscarriage Multiple sclerosis Mumps Numbness/tingling Pace maker Osteoporosis Pneumonia Polio Rheumatic fever Stroke Thyroid disease Tuberculosis Ulcers Other
5 Daily Record of Food Intake Each day, record all the items you eat and drink. Be sure to include the appropriate amount of each item. Also note your digestion and energy. Name: of Birth Day 1 - : Breakfast Time: Lunch Time: Dinner Time: Mid Morning Snack Time: Mid-Day Snack Time: Nighttime Snack Time: Bowel Movements (# and consistency): Hours of Sleep: Quality of Sleep: (good) (poor) Lunch Time: Dinner Time: Mid Morning Snack Time: Mid-Day Snack Time: Nighttime Snack Time: Bowel Movements (# and consistency): Hours of Sleep: Quality of Sleep: (good) (poor) Lunch Time: Dinner Time: Mid Morning Snack Time: Mid-Day Snack Time: Nighttime Snack Time: Bowel Movements (# and consistency): Hours of Sleep: Quality of Sleep: (good) (poor) Vegetables and Fruit: Breads, Cereals and Grains: Fats (butter, oils etc): Candy, Sweets & Junk Food: Fluid Intake: Supplements / Medications: Day 2- : Breakfast Time: Vegetables and Fruit: Breads, Cereals and Grains: Fats (butter, oils etc): Candy, Sweets & Junk Food: Fluid Intake: Supplements / Medications: Day 3- : Breakfast Time: Vegetables and Fruit: Breads, Cereals and Grains: Fats (butter, oils etc): Candy, Sweets & Junk Food: Fluid Intake: Supplements / Medications:
6 Patient Measurement Form Please have a partner help you with your measurements. Follow the simple guide Name: of Birth Body Part Neck Shoulders Right Biceps Chest Waist (Belly Button) Hips (Widest Part) Right Upper Thigh Right Calf Total Inches Weight Where to measure Neck - At the widest part of the neck Shoulders - With the arms resting at your side Right Bicep - With the arm resting at the side at the widest part of the arm Waist - With the core muscles relaxed, measurement taken at the belly button Hips - Widest part of the hips Right Thigh - Taken at the widest part of the right upper thigh Right Calf - Taken at the widest part of the right calf Note : When taking the measurement, ideally it should be done on the skin (clothing removed) and with a gentle tug.
7 First Appointment Instructions The samples collected during your exam will determine how your body s bio-chemistry work. Please follow the below instructions closely for the date of your first appointment. This is very important, please call in advance if you have any questions. Name: of Birth Sample Requirements (Please check that you have understood and followed these instructions) Consume a serving of protein and a serving of carbohydrate 2 hours before your test. Water up to 1 hour before. Do not consume anything by mouth 1 hour before your test including water. Do not brush your teeth up to 3 hours before your test. No lipstick or makeup day of test. No coffee, caffeinated beverages, soda or alcohol the day of test. No chewing gum on day of test ACCEPTABLE forms of Protein: Handful of Nuts or seeds 4-6 ounces of unprocessed meat 1-2 eggs 1/2-1 cup of legumes (tofu, beans etc.) ACCEPTABLE forms of Carbohydrates: 1-2 cups vegetable 1 cup of fruit 1 cup Whole Grain/Oat items 1 cup of rice (brown/wild/white) NON-acceptable forms of protein: Processed meat or proteins Lunch meat NON-acceptable forms of carbohydrates: Cookies Candy Refined/Processed sugars and breads Your ideal meal is: 1 cup of cooked oatmeal 1 banana 1 egg or 1 bagel or 2 slices of any bread 1 banana 1 tablespoon of peanut/almond butter Please indicate what you ate before your appointment: Time of Meal: Office Use Only Time of Collection: Blood Sugar:
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Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
Placer Private Physicians: Patient Health Questionnaire [2]
![Placer Private Physicians: Patient Health Questionnaire [2]](/thumbs/87/96006031.jpg "Placer Private Physicians: Patient Health Questionnaire [2]")
Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
Full Name Preferred name. Home Street Address. City, State, Zip. Cell phone Home or Work. # Children Ages:
Health History Full Name Preferred name Home Street Address City, State, Zip Cell phone Home or Work Email # Children Ages: Occupation Hours/day on computer Hours/day sitting Who can we thank for referring
Reason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Dr. Michelle Cruickshank
CHIROPRACTIC INTAKE FORM A Multidisciplinary approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best of
HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
Naturopathic New Patient Form
611 Main St., Suite A Edmonds, WA 98020 Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Email: Marital Status: Emergency Contact:!!!!
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced