Patient Information Form

PERSONAL INFORMATION

Introductory Patient Information

First Name *

Last Name *

Date *

Street Address *

Date Of Birth *

Address Line 2

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number *

Email address *

Martial Status *

How did you hear about us? *

Who can we thank for your referral?

Who is your primary physician? *

List Children and their ages:

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Have you or your family experienced any major life changes? *

Yes

No

If yes, please comment

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Have you experienced any major losses in life? *

Yes

No

If so, please comment

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Please list your highest level of education: *

Do you have learning difficulties? *

Yes

No

COMPLAINTS/CONCERNS

Please list your chief symptoms in order of decreasing severity. Please note when the symptom started.

	Symptom	Onset	Frequency (ex. 1x/week)
1.	Symptom	Onset	Frequency (ex. 1x/week)
2.	Symptom	Onset	Frequency (ex. 1x/week)
3.	Symptom	Onset	Frequency (ex. 1x/week)
4.	Symptom	Onset	Frequency (ex. 1x/week)

What diagnosis or explanation has been given to you? *

How much time have you lost from work or school in the last year? *

<2 days

3-14 days

> 15 days

When was the last time you felt well? *

Did something trigger your change in health? *

What makes you feel WORSE? *

What makes you feel BETTER? *

PAST MEDICAL & SURGICAL HISTORY

Please list any and all past medical/surgical history: (ex. kidney stones in 1991 or anemia when pregnant with 1st child in 2000)

CHILDHOOD HEALTH HISTORY

Do you have any history with Childhood Illness? Allergies, colds/flu, behavior problems, ear infections, skin disorders, etc. If no, just type "none" in the box below. *

Did you require more than 5 courses of antibiotics as a child (ages 0-12)? *

Yes

No

FEMALE MEDICAL HISTORY (for women only)

Age at first period

Menses Frequency

Do you have pain with your period?

Date of last menstrual period

ESTABLISHING HEALTH GOALS

PERSONAL MESSAGE

I have read something interesting: “The definition of insanity is to keep doing the same thing and expecting different results”. If you keep following the same course of treatment you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to reach your destination.

Most people I ask tell me they’re made the decision to change. But how many people have truly decided to change? Very few! Why? Because there is a big difference between deciding something and having “reasons” to actually do it.

When you have made a decision to make a change and you know your reasons, you create an internal power that can propel you to achieving health and wellness.

What do you hope to achieve with your visit here with us? *