Fillable New Patient Questionnaire

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New Patient Questionnaire

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The New Patient Questionnaire form is 7 pages long and contains:

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  • 40 check-boxes
  • 128 other fields

Country of origin: OTHERS
File type: PDF

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Page 1 of 6
NEW PATIENT QUESTIONNAIRE
Date ___________________ E-Mail Address __________________________
First
______
_____________ Middle ___________ Last ____________________
Home Address
____________________________________________________
City, State, Zip ____________________________________________________
Home Phon
e ( )
_____________________ Cell ( ) ___________________
Birth Date ___________ Current Age _______ S.S.N. _____________________
Referral Name _____________________________________________________
Marital Status
_______________________ No. of Children __________________
Children’s Ages
______________________
Your Occupation
___________________________________________________
Patient’s Employer _________________________________________________
Business Address __________________________________________________
City, State, Zip __________________________________________
Business Phone ( ) ______________________
Name of Spouse _______________________ Spouse’s S.S.N. ______________
Primary Insurance Company _________________________________________
Name of Insured ___________________________________________________
Group No. / Policy No. ______________________________________________
Secondary Insurance Company _______________________________________
Group No. / Policy No. ______________________________________________
I clearly understand and agree that all services rendered to me are charged directly to
me, and that I am personally responsible for payment. I also understand that if I suspend
or terminate my care and treatment, any fees for professional services rendered to me
will be immediately due and payable.
Signature _______________________________________ Date _____________
Please Note: You will not be able to save your work!
You may type directly into this form. Click the "Highlight fields" checkbox to
outline form elements. These notes will not appear when you print this form.
Bring this completed form to your first visit.
Page 2 of 6
Background Information:
Primary Physician ________________________ Phone ____________________
Date of Last Physical Exam __________________________________________
Abnormal Findings _________________________________________________
Date of Last Blood Test _____________________________________________
Abnormal Findings in Blood Test ______________________________________
Date of Last PAP Smear (Females Only) ________________________________
Abnormal Findings in PAP (Females Only) ______________________________
Date of last Mammogram (Females Only) _______________________________
Abnormal Findings in Mammogram (Females Only) _______________________
Present complaint(s) or illness(es):
_________________________________________________________________
Illness Duration ____________________________________________________
Events preceding onset:
How long since you’ve been well ______________________________________
Personal Health Goals:
List travel immunizations ____________________________________________
Recent flu shots ___________________________________________________
Do you have mercury amalgam fillings? ________ If yes, how many? _________
Do you have root canals? ______________ If yes, how many? ______________
Page 3 of 6
List any Accidents you have had with dates:
List any Surgeries you have had with dates:
Medications that you are currently taking (include birth control pills and non-
prescription drugs, including vitamins/supplements). Indicate the dosage, length
of time taking the medication, and frequency of use.
Have you ever had a frequent or prolonged use of the following drugs, if so,
provide your age at the time and for how you took them?
Antibiotics ________________________________________________________
Antihistamines _____________________________________________________
Cortisone _________________________________________________________
Prednisone _______________________________________________________
Steroids __________________________________________________________
Describe how you feel about these issues (G=Great / O=Okay / P=Problem):
Spouse _________
Significant other _________
Children _________
Work _________
Sex Life _________
Finances _________
Describe how you feel about your life in general:
_______________________________________________________________
Do you smoke cigarettes now? ______________ Have you smoked? _________
Page 4 of 6
How much? ______________ How long? ______________
Alcohol Usage: Alcohol Type_________________________________________
Alcohol Amount__________________ Frequency_________________________
Do you now or have you ever had a problem with drugs? ___________________
If yes, describe:____________________________________________________
How often do you exercise? ______________
What type of exercise? _____________________________________________
For how long? _____________________
Would you describe your stress levels as low, moderate or high? ____________
Describe the kind of work you do:______________________________________
How often do you have bowel movements?______________________________
What kind of water do you drink? ______________________________________
Do you have a purifier? ____________ What kind? _______________________
Do you use an electric blanket? _______________________________________
List any allergies or sensitivities to drugs, supplements, herbs, foods, pollens,
animals, or chemicals:
Page 5 of 6
For the following illnesses, check the box if you have now or have had them, and
include description, now vs. prior, treatment/action taken, and dates:
Cancer _______________________________________________________
AIDS/ HIV _____________________________________________________
High Blood Pressure ____________________________________________
Elevated cholesterol ____________________________________________
Diabetes _____________________________________________________
Heavy Metal Toxicity ____________________________________________
Major Dental Problems __________________________________________
Rheumatoid Arthritis ____________________________________________
Lupus/ Auto-Immune illness ______________________________________
Multiple Sclerosis ______________________________________________
Hepatitis/ Liver Disease _________________________________________
Gall Stones ___________________________________________________
Kidney Stones ________________________________________________
Low blood Pressure ____________________________________________
Hypoglycemia ________________________________________________
Candida _____________________________________________________
Food/ Environmental Allergies ____________________________________
Anemia ______________________________________________________
Asthma ______________________________________________________
Breast Cysts __________________________________________________
Osteoporosis _________________________________________________
Endometriosis ________________________________________________
Weight Disorder _______________________________________________
PMS ________________________________________________________
Excessive Fatigue _____________________________________________
Miscarriage(s) ________________________________________________
Abdominal Pain _______________________________________________
Ovarian Cysts ________________________________________________
Gonorrhea/ Syphilis/ Chlamydia __________________________________
Fibroid ______________________________________________________
Herpes ______________________________________________________
Shingles _____________________________________________________
Ulcerative Colitis/ Crohn’s Disease ________________________________
Depression/ Nervous Breakdown __________________________________
Insomnia _____________________________________________________
Attempted Suicide ______________________________________________
Mono/ EBV/ CMV ______________________________________________
Pneumonia ___________________________________________________
Eczema/ Psoriasis ______________________________________________
Thyroid Disease ________________________________________________
Page 6 of 6
Additional Questions:
1) What % of your body’s healing power do you feel you are using now?_______
2) How long do you think it will take for you to regain your health?
________________________________________________________________
3) What lifestyle/dietary changes do you think you need to make to feel better?
________________________________________________________________
4) What emotional or stress-related factors are of concern to you currently?
________________________________________________________________
5) What do you do to reduce stress in your life?
________________________________________________________________
6) How will your life be different when you regain your health?
________________________________________________________________
7) How can I help you reach a state of OPTIMAL HEALTH?
________________________________________________________________________
Thank you for taking the time to complete this and for your thorough answers.
Female Hormone Questionnaire
initials
~._
.......
_
Current
Age
Approximate date of last menstrual period
Approximate date of last menstrual period at time when your periods were regular
Age of onset of menstruation (Menarche)
How
long
after Menarche did your periods get regular?
How many days did your menstrual flow last
at
that time?
What
was
cycle length when periods got regular at that time?
(number
of
days
from
the
first
day
of
menstrual
flow
of
one
cycle,
to
the
first
day
of
flow
of
the
next)
Prior
to
the
age
of
18
or,
your first pregnancy:
did
you
have
"PMS"
_yes
_no
did
you
have
difficult periods
_yes
_no
? breast tenderness:
_yes
_no
? headaches:
_yes
no
_irritabiility?
_uterine
cramps? _ heavy flow?
_bloating?
Birth control methods:
_.
Diaphragm
_Condom
_both
_IUD
[_#
of
years]
_tubal
ligation
Were
you
ever
on
the Birth Control Pill?
_yes
_no
_#
of
years or of months
If 'yes', how did you feel
on
it?
_better
worse
did you"gain weight while
on
it?
yes
no
Number of
"""_miscarriages
_abortions
Have
you
ever
been
pregnant &given birth?
_yes
_no
if yes, number
of
births _
Your
age at each pregnancy
Number of months you breast
fed
this baby
__
After the first 3 months was pregnancy
a very physically pleasant time for you?
yes
a worse time for you than
non~pregnant?
yes
no
did
you
have diabetes during pregnancy?
yes
no
did
you
have nausea of pregnancy?
yes
no
for how long?
__
Have
you
had
a recurrance or worsening of premenstrual symptoms after the age of
35:
~es
_no
_PMS
_breast
tenderness
After
the
age
of
35,
before menopause,
Is
there a time
of
the month that you feel best?
Is
this
the only time of the month you feel good?
week: 1
~es
_no
2:
3:
4
Breast
size
when younger
or,
prior
to
first pregnancy:
_small
_medium
_large
Current breast size:
_smaller
than above
_larger
than above
have
you
had
any
of
the following:
_ breast cysts
_breast
biopsy breast cancer
have
you
had
breast mammograms? if
so,
how
many ? anyabnormal
__
?
have
you
had
breast ultrasounds? if
so,
how many ? anyabnormal
__
?
have
you
had
breast thermograms? if
so,
how many ? any abnormal
__
?
do
you
have breast implants (if
so,
when implanted
?)
what percentage
of
time
in
a 24 hour day
do
you
wear a bra? %
Page
82
The remainder of the New Patient Questionnaire must be completed by hand. We
recommend filling out the above questions, printing the document, and then
continuing if this section applies to you.
---
Have you had any
of
the following:
uterine fibroids
_D
& C L # of]
_ovarian
cysts endometriosis
_Iaparoscopic
surgeries
_cesarian
sections
_tubal
ligation
_endometrial
biopsy
_hysterectomy:
at what
age_?
_oopherectomy
[removal of
ovary(s)]
? 1 ? 2
_age
of
last pap smear
_?
abnormal pap smear [at what
age_?
]
_bone
density tests date of last one
_normal
_osteopenia
_osteoporosis
Hormonal use: Premarin
_Provera
_patch
_other
hormones
[list],
________________________
_
has any woman
in
your family had female cancer? no
_yes
if yes, who and what type?
_breast
_uterine
ovarian
who?
Current Height
__
feet inches
tallest height you ever were
__
feet
_"
_inches
Weight age
25
__
lbs Weight now
__
Ibs
In
your life have you had more muscle and hair than others?
more muscle than others with little body hair?
__
?
Symptoms
of
estrogen deficiency:
hot flashes warm rushes
_temperature
swings
_night
sweat
_kicking
covers off at night
_vaginal
dryness racing mind @ night
_trouble
falling asleep
_mental
fogginess
_depression
_headaches
& migraines
_intestinal
bloating
_diminished
sexuality & sensuality
_weight
gain
_back
& joint pain
_heart
palpitations
Symptoms
of
estrogen excess:
_breast
tenderness [especially central]
_breast
swelling
or
enlarging
_water
retention & swelling
_impatient
& snappy though with clear mind
_pelvic
cramps
_nausea
Symptoms
of
progesterone deficiency:
_difficulty
sleeping
_anxiety
& nervousness
water retention
_no
period
_infrequent
period
_shorter
cycle
_frequent
& heavy periods
_spotting
before period
PMS
_cystic
breasts
_painful
breasts
_e
ndometriosis
fibroids
Symptoms
of
testosterone deficiency:
_diminished
sex drive
_flabbiness
_diminished
energy & stamina
_diminished
sense
of
security
_diminished
coordination & balance
indecisive!,less
_diminished
armpit, pubic & body hair
-fa~jr8~oss
_diminished
love
of
your body image
_muscle
weakness
QUESTIONSFORPATIENTS
1) Whatisyourmaincomplaint,andwhy,andhowdoesittroubleyou?
2) Doyouhavepain,andrateitonascaleof1‐10.
3) Whatdoyouexpectthistypeofmedicine,andparticularlythedietchanges,todoforyou?
4)
Wereyoubreastfed,andforhowlong?
5) Asachild,wereyoususceptibletoinfections
6) Haveyourtonsilsoradenoidsbeenremoved?Orhaveyouhadanappendectomy?
7) Asachild,didyouhaveeczema,anyotherskinproblems,orallergies?
8) Doyouhavemercuryfillings
orrootcanals?
9) Haveyouhadalotofantibiotics?
10) Whatvaccinationshaveyoureceived?
11) Areyoufollowinganyparticulardiet?
12) Doyouoftenfeelverytiredafterameal?
13) Doyouoftengetattacksofintensehunger,sothatyousimplyhavetoeatsomething?
14) Doyouhaveregularbowelmovements?
15) Arethereanyfoodsthatyoudonottolerate,orareespeciallyfondof?
16) Howmuch,andwhat,doyoudrinkeveryday?
17) Doyousleepwell?Doyousnore?
18) Whatareyoumostafraidof?
19) Whatdoyou
considertobethecauseofyourproblem?
20) Imaginethatawizardcamealongandcouldgrantyouonewish,butyoucan'trequestawishfor
healingortoreceivemagicalpowerstochangeeverything.Whatwouldyouwishfor?
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Completed 19 July 2020

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