New Patient History Form
New Patient History Form
Name: ______Date: _____/______/_____
Date of Birth: ______/______/______
Age: ______Height ______Weight ______
Address: ______
Phone:M______H______
E-Mail: ______
Occupation: ______
Would you like to receive updates and information? Y / N
Emergency Contact:
Name: ______Phone:______
Relationship: ______
Primary physician: ______
How did you find me? ______
Have you tried natural medicine, homeopathy, acupuncture, Oriental medicine and/or herbalmedicine before?______
Cancellation Policy:
This practice maintains a 24 hour cancellation policy: all appointments must be cancelled orrescheduled 24 hours before the appointment time, or the full consultation charge will beapplied to the patient’s account.
Chief Complaint(s)
Main problem(s) with which you'd like help:
______
Date of accident/injury/onset ______
Have you had this problem before? ______
Have you tried other treatments? Y / N
What type? ______
Have you been given a diagnosis for this problem?
______
General Information:
Please list any medications (prescribed and over-the-counter), vitamins and supplements you are currently taking or have taken in the past 2 months:
______
______
Do you have an infectious disease? YES / NO______
Family History: Do you have a family history of any of the following diseases or conditions?
___Heart Disease
___Diabetes
___High Blood Pressure
___Stroke
___Epilepsy/Seizures
___Other ______
Do have any allergies (seasonal, food, medications, etc)?
______
______
Please list any medications including oral contraceptive:______
______
If you suffer aches, pains or other uncomfortablesensations, please mark affected areas on the diagram below:
Do you have any additional comments or information we should know to further your treatment?
______
______
______
Review of Systems
( markfrequently experienced with “o,” sometimes experienced with “x”)
Immune/Respiratory/Sinus:
___ Swollen Glands
___ Frequent colds/flus
___ Cough
___ Asthma
___ Shortness of Breath
___ Congestion
___ Wheezing
___ Sinus Stuffiness/Pain
Head/Eyes/Ears:
___ Headaches
___ Migraines
___ Jaw pain/TMJ
___ Impaired hearing
___ Earaches/infections
___ Ringing
___ Floaters/spots
___ Blurriness
___ Eye Pain/Strain
___ Dryness
Musculoskeletal:
___ Spasms/Cramps
___ Weakness
___ Nerve Pain
Mental/Emotional:
___ Depression
___ Mood Swings
___ Poor concentration
___ Anxiety
___ Tension/Stress
___ Memory problems
___ Seasonal Depression
Neuroendocrine:
___ Hair Loss
___ Brittle Nails
___ Excessive Fatigue
___ Night Sweats
___ Vertigo/dizziness
___ Numbness/Tingling
Skin:
___ Rashes
___ Acne/Boils
___ Lumps
___ Eczema
___ Hives
___ Itching
Urinary:
___ Pain
___ Frequency
___ Frequent Infections
___ Incontinence
___ Kidney Stones
Cardiovascular:
___ High Blood Pressure
___ Low Blood Pressure
Intestinal:
___ Change in Appetite
___ Nausea
___ Vomiting
___ Gallstones
___ Heartburn
___ Excess Gas
___ Constipation
___ Diarrhea
___ Hemorrhoids
Blood/Peripheral Vascular:
___ Easily Bruise/Bleed
___ Varicose Veins
___ Cold hands/feet
___ Palpitations/Fluttering
Female Reproductive
Age of first period _____
Date of last menses onset: ______days between periods______
If you are pregnant, what is your due date? ______
Do you experience
___Bleeding between periods
___Clots in menses
___Excessive menstrual flow
___Extreme menstrual pain
___Irregular cycle
___Menopausal symptoms
___PMS
___Previous miscarriage
___Scanty menstrual flow
Please describe any PMS symptoms you experience:______
______
Date of last annual exam/Pap Results: ______
Male Reproductive
Have you experienced any pain or other symptoms related to sexual function/dysfunction?
If yes, please describe: ______
Have you experienced changes in urination unrelated to fluid intake?
If yes, please describe: ______
If you have been unable to conceive, have you had medical testing for this issue? Y / N If so, what were the results? ______
______
If you are currently undergoing IVF, who is your consulting doctor?
______
All information is treated as confidential and will not be released without consent.
Signed: ______Date______