Name:

Age:

Sex:

M

F

DOB:

Today's Date:

Street Address:

City:

State:

ZIP:

Home Phone:

Cell Phone:

May we leave a voicemail?

Y

N

Email Address:

How did you hear about us?

Employer:

Occupation:

Length of Employment:

Height:

Approximate Weight:

1. Main Problem(s):

2. In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else. In your own words and your own opinion, what do you think the real problem is:

3. When were you diagnosed with your current condition:

What diagnostic tools were used to achieve your diagnosis?

4. What are the three things your condition has caused you to miss most:

5. Symptoms (list all):

6. Severity of problem (choose one):

Minimal (annoying but causing no limitation)

Slight (tolerable but causing a little limitation)

Moderate (sometimes tolerable but definitely causing limitation)

Severe (causing significant limitation)

Extreme (causing near constant limitation (>80% of the time))

7. What relieves your symptoms or causes them to return:

8. Describe the first time you remember having symptoms:

9. Do your symptoms include pain:

Y

N

10. Do your symptoms occur at a specific time, place, or environment:

Y

N

When and for how long do symptoms last each episode:

13. What are you hoping happens today as a result of your consultation:

14. How often are you aware of your main problem (choose one):

Occasionally (25% of the time)

Intermittently (50% of the time)

Frequently (75% of the time)

Constantly (100% of the time)

15. If you cannot find a solution to your problem what do you think will happen?

16. Due to your condition have you lost time from (describe how much time and what tasks have been limited)?

Work:

Y

N

Describe:

Family:

Y

N

Describe:

Leisure Activities:

Y

N

Describe:

Please list all prescriptions, over-the-counter medications, and supplements you are taking:

Approximately how many times have you used antibiotics?

When was the last time?

Have you been exposed to:

Surgeries/Hospitalizations & Dates:

Traumas & Dates:

Past/Recent Illnesses & Dates:

Family History (Mother, Father, Siblings, Spouse and or Partners, Children) & Dates:

Do you:

Drink Alcohol:

Y

N

# of Drinks/Week:

Use Caffeine:

Y

N

# of Cups/Day:

Smoke (Tabacco, E-Cigs, or anything else):

Y

N

# of Packs/Day:

Chew Tobacco:

Y

N

# of Times/Week:

Allergies/Other (Drugs, Food, or Environmental):

Recent Tests (Lab Work, X-Rays, Ct, Or Mri):

Other Providers:

New Patient Application and Case History