CONFIDENTIAL PATIENT INFORMATION

**PLEASE PRINT CLEARLY AND COMPLETE ONLY FIRST TWO PAGES **

Today’s Date: _________________ Birthdate:____________ First Appt. Date: ____________

Name: (First)____(Middle) (Last)

Telephone: (HM) _________________________ (WK) ______________________________

(FAX) __________________________ (E-MAIL) ___________________________

Address: _________________________________ Soc Sec # ___________________________

_________________________________________ Age: __________ Sex: _________

Specific Confidentiality Requests (e.g. “Don’t leave messages on home phone recorder”): __________________________________________________________________

General Problem(s) you would like assistance with: ________________________________________

______________________________________________________________________________

Your Occupation: _________________________ Employer: ___________________________

Marital Status: S M D W Live w/Someone How Long? _____________________

Spouse/Partner Name: ____________________________ Okay to Contact? Y N

Spouse’s Occupation: ____________________________ Phone (WK): __________________

Children (Name/Ages): _____________________________________________________

______________________________________________________________________________

Parent/Guardian: ________________________________ Phone: _______________________

How did you learn about us? (If Yellow Pages, what listing?)________________________________

Emergency Contact: _______________________________ Phone: __________________

General Physician (Name/City/Phone): __________________________________________

Other Physician (Name/City/Phone): ___________________________________________

Other Contact: ____________________________________________________________

I understand and agree that I am responsible for making payment for professional and other services at the time that they are rendered and agree to have my credit/debit card charged for legitimate account balances over 30 days old. I agree to read carefully all of the new patient and recipient rights information given to me and ask questions if necessary. I certify that I will notify you immediately if I am a Medicare or Medicaid recipient. I will notify you of any changes in the information I am providing today. I authorize you to release and receive demographic, diagnostic, prognostic, and clinical data and/or progress reports to or from my insurance carrier, and the above named health care provider(s) and other parties for the purposes of diagnosis and treatment while I am under your care. I agree that I am responsible at all times for my own safety and welfare and that I am solely responsible for decisions I make based on the professional advice I receive.

SIGNATURE: __________________________________ DATE: ___________________

CONFIDENTIAL MEDICAL INFORMATION

Describe any current medical problems: ____________________________________________________________

__________________________________________________________________________________________

Any lab tests in the past 12 months? ______________________________________________________________

Any medicine allergies/reactions or sensitivities? _____________________________________________________

Please list all medications, including herbs, you are now taking:

1. ______________________________________ 4. _________________________________________

2. ______________________________________ 5. _________________________________________

3. ______________________________________ 6. _________________________________________

Please mark any of the below medications you have taken. Put a “P” for past, and/or a “C” for current:

______ Seizure Medication ______ Alcohol ______ Recreational Drugs

______ Drugs for GI Distress ______ Benzodiazepines ______ Migraine Drugs

______ Hormones ______ Serotonin Reuptake Drugs ______ Pain Medications

Medical Conditions/Symptoms

Any abnormalities around the time of your birth? (prematurity, breathing difficulties, etc) _____________________

___________________________________________________________________________________________

Were you often sick as a child? ___________________________________________________________________

Have you taken frequent or repeated antibiotics? ______________________________________________________

Please mark ALL the following that apply to you. Put a “P” for past, and/or a “C” for current conditions:

______ High blood pressure ______ Anemia or blood disorder ______ Low blood sugar

______ Fainting/loss of consciousness ______ Chronic cough or lung disease ______ Diabetes

______ Seizures (even in childhood) ______ Snoring or other sleep disorder ______ Rashes or itching

______ Feeling chilly or warmish often ______ Tingling or numbness ______ Tumor, cancer

______ “Brain fever” or meningitis ______ Adrenal insufficiency ______ Hearing problem

______ Severe or unusual headaches ______ Dizziness/lightheadedness ______ Heart condition

______ Sexually transmitted disease ______ Eye or visual problems ______ Severe head injury

______ Worsening aches/pains ______ Jaundice/liver trouble ______ Thyroid condition

______ Allergies (pollen, dust, etc) ______ Stomach or bowel trouble ______ Head injuries

______ Disease of male/female organs ______ Blood in urine or stools ______ Low-DHEA levels

______ Hormonal disregulation ______ Pituitary abnormalities ______ Walking trouble

______ Rheumatoid arthritis ______ Kidney, bladder, or prostate problems

______ Others: ______________________________________________________________________________

Have any blood relatives had:

Diabetes? ________________________________ Heart disease under 55 years? _________________________

Hereditary disease of any sort? _______________________________ Suicide? _____________________

Depression, anxiety or other psychological conditions? _______________________ Alcoholism? ___________

Thyroid condition? _________________________ Alzheimer’s dementia? _______________________________

Others: ____________________________________________________________________________________

Do you smoke? ________ In the past? ________ How much? _________________ How long? _______________

Do you take alcohol? ____________ Average number of drinks per week? ________

Do you use “recreational” drugs? __________ Did you in the past? _________

Were you ever told you were taking too much alcohol or drugs? _________ Your height ___________

Do you exercise regularly? ___________ Take any vitamins? __________ Dressed weight ________

Any recent gain or loss of weight? ___________ If yes, # of pounds gained/lost, _________, since _____________

Are you on a special diet? ______________________________________________________________________

Is it possible you may have been exposed to the HIV/AIDS virus, thru needles, blood, or sexual contact? _________

For Women Only

Any menstrual problems? ______________________________ Severe premenstrual symptoms? ______________

Recurrent vaginal infections? __________ Last menses began ____________ Are your cycles regular? _________

Number of pregnancies? ___________ Number of living children? ______

PROCEDURE TRACKING FOR _______________________________

Date Started Procedure / Medication Status Change

__________ __________________________________________ ________________________

CONFIDENTIAL PATIENT INFORMATION

Name: (First)____________________(Middle) ____________ (Last) ________________

CONFIDENTIAL MEDICAL INFORMATION

Medical Conditions/Symptoms

For Women Only

Name: (First)____(Middle) (Last)