Our approach to health care is different than the conventional model.

We utilize a holistic approach and treat mind, body and spirit. We combine the modalities of modern medicine and alternative medicine, often incorporating chiropractic care, massage therapy, nutrition education and exercise in our treatment plans. FILLING THIS OUT ACCURATELY AND COMPLETELY PRIOR TO YOUR VISIT IS NECESSARY TO MAKE THE MOST EFFECTIVE USE OF OUR TIME TOGETHER. Patients that have entered data on the Patient Portal may skip all of the sections in purple.

Name

______________________________________

Todays Date____________________

Address __________________________________________________________City, State, Zip ___________________________ Telephone ______________________________ Date of Birth __________________ Country of Birth _____________________ Email: ____________________________________________________How did you hear about us? ________________________

My Providers: Do you have another health care practitioner that you will continue to see for primary care? Yes/No Are you under the care of any specialists? Yes/No Please list your providers (including non-allopathic and others helping you in your healing and wellness): Name Address Telephone

Last physical exam: Date __________________ Results ______________________________________ List 3 main areas or concerns you want to discuss today (If more than 3, multiple appointments may be necessary to adequately cover). 1.)

2.)

3.) My Allergies: To medications _______________________________________________________________ Other allergies ________________________________________________________________ Medication intolerances _________________________________________________________

Past Medical History:

When did it start?

Alcoholism Anemia Arthritis Atrial fibrillation Circulatory system disorder Depression Emphysema Headache Heart attack Herniated Disc High cholesterol Hypothyroid Irritable bowel syndrome Migraine Osteoporosis Skin disorder Visual impairment Fibromyalgia Urinary Incontinence Others not listed

Allergic rhinitis Anxiety Asthma Chest pain Congestive heart failure Diabetes Gout Hearing loss Heartburn High blood pressure [hypertension] High lipids Insomnia Kidney failure Mitral valve disorder Sinusitis Stroke Smoking Menopause

Past Surgical History: Surgery/Procedure Date Doctor Hospital

When did it start?

Present

Present

Absent

Absent

My Family History:

Family Member (s)

Allergic rhinitis Anxiety Asthma Chest Pain Congestive heart failure Diabetes Gout Hearing loss Heartburn High blood pressure (hypertension) High lipids Insomnia Kidney failure Mitral valve disorder Sinusitis Stroke Smoking

Anemia Arthritis Atrial fibrillation Circulatory system disorder Depression Emphysema or COPD Headache Heart attack Herniated Disc High cholesterol Hypothyroid Irritable bowel syndrome Migraine Osteoporosis Skin disorder Visual impairment Unknown

My Immunizations: Rubella (German measles) Rubeola (Measles) Mumps Varicella (Chicken pox) Hepatitis B Polio Tetanus & Diphtheria Pneumovax

Had illness Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

Been immunized Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

Date last immunized __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________

Family Member (s)

Conditions

Conditions

Present

Present

My Medications: Prescriptions (including oral contraceptives): Prescription Medication How taken (oral, patch, injected, etc.) Purpose

Non-Prescription (i.e. aspirin, laxatives, vitamins, minerals, herbs or nutrients): Non-Prescription/Supplements How taken Purpose

Social Habits: Tobacco use: Yes No Alcohol use: Yes No Type: Beer Wine Liquor (Circle one you use most) Number _____Per Day/Week/Month Former Type _____________ Packs/Day now or before quit _____________

Have you ever felt you should cut down on your drinking? Yes No Has anyone criticized your drinking? Yes No Have you felt bad or guilty about your drinking? Yes No Have you ever had a drink first thing in the morning to steady your nerves? Yes No Recreational drug use: Yes Seat belt use: Yes No No No _________ No Type _____________ Amount_____________

Regular dental care: Yes

Do you know your cholesterol level (if so, please list)? Yes

Additional Social History Marital status _________________________________________________________________ Children: Yes No (ages) ______________________________________________________ Number of people living in your household? _________________________________________ How much formal education have you had? _________________________________________ Occupation: ____________________________________ How long: _____________________ Where: ________________________________________ Doing what: ___________________ Please list any major sources of stress in your life: _____________________________________ _____________________________________________________________________________ Do you meditate/pray/use relaxation techniques? Yes No (how much and how often) ________ Are you satisfied with your ability to be in a relationship? Why yes or no? ___________________ Are you having problems getting along with anyone in your family? _________________________ Have you been hit, kicked, punched, or threatened by a partner or ex-partner? _______________ Please list strengths & goals in the following areas: Physical_______________________________________________________________________ Mental ________________________________________________________________________ Spiritual_______________________________________________________________________ Hobbies and Interests ___________________________________________________________

Diet and Exercise Habits Do you follow a special diet? Yes No (if yes, please describe below)

How many servings on milk/milk products do you get per day? ___________

Caffeine use? Yes No

Do you exercise? Yes No (if yes, please describe the kind(s) and how often)

Aerobic?

Weight training?

Review of Systems
General

Condition

Comments

Denies fevers, chills, sweats, anorexia, fatigue, sleepiness, sleep problems, malaise, weight gain, weight loss Fevers Chills Sweats Anorexia, loss of appetite Fatigue Sleepiness Sleep problems Malaise Recent weight change Weight gain Weight loss Satisfied with current weight

You may simply check yes on this line if no general complaints

Eyes

Condition Denies eye pain, vision loss, excessive tears, blurring, diplopia, irritation, discharge, photophobia Eye pain Vision loss Excessive tears Itching Blurring Diplopia Irritation Discharge Photophobia (sensitive to light)

Comments You can simply check yes on this line if no eye complaints

See HPI

Current

Yes

No

See HPI

Current

Yes

No

Ear, Nose, Throat

Denies ear pain or discharge, tinnitus, decreased hearing, nasal obstruction or discharge, nosebleeds, sore throat, hoarseness, dysphagia Earache Ear discharge Tinnitus Decreased hearing Nasal congestion Nosebleeds Sore throat Hoarseness Ddysphagia (trouble swallowing)

You can simply check yes on this line if no ear, nose, or throat complaints

Cardiovascular

Denies chest pains, palpitations, syncope, dyspnea on exertion, orthopnea, PND, peripheral edema Chest pains Palpitations (noticeable abnormal heartbeat) Syncope (fainting or blacking out) Orthopnea (shortness of breath while lying down) Peripheral edema (swelling in legs or feet) Paroxysmal nocturnal dypsea (waking from sleep unable to breathe) Dyspnea on exertion (shortness of breath during exercise)

You can simply check yes on this line if no cardiovascular complaints

Respiratory

Denies cough, dyspnea, excessive sputum, hemoptysis, wheezing Trouble with nose or sinuses Wheezing Dyspnea (shortness of breath) Excessive sputum (phlegm)

You can simply check yes on this line if no respiratory complaints

See HPI

Current

Condition

Comments

Yes

No

See HPI

Current

Condition

Comments

Yes

No

See HPI

Current

Condition

Comments

Yes

No

Condition

Comments

Hemoptysis (coughing up blood) Cough, productive Cough, dry

Gastrointestinal

Denies nausea, vomiting, diarrhea, constipation, change in bowel habits, abdominal pain, melena, hematochezia, jaundice Constipation Diarrhea Vomiting Nausea Heartburn or reflux Abdominal pain Change in bowel habits Melena (black or tar-like stool) History of ulcer Hematochezia (blood in stool) Jaundice (yellow skin) History of liver or gallbladder disease History of binge eating, purging, or laxative use for weight control

You can simply check yes on this line if no gastrointestinal complaints

Genitourinary (Female)

Denies urinary symptoms, vaginal discharge or sores, menstrual irregularity Urinary frequency Incontinence (unable to hold urine) Hematuria (blood in urine) Dysuria (pain when urinating) Frequent urinary tract infections Kidney stones Pelvic pain

You can simply check yes on this line if no GU complaints

See HPI

Current

Womens Health Section

Comments

Yes

No

See HPI

Current

Condition

Comments

Yes

No

See HPI

Current

Yes

No

Condition

Comments

Genital sores Vaginal discharge Abnormal vaginal bleeding Amenorrhea (absence of period) Menorrhagia (heavy periods) Vaginal dryness Sexually active Prefer male Prefer female No preference History of sexual abuse

Genitourinary (Male)

Denies dysuria, nocturia, hematuria, impotence, discharge, hesitancy, incontinence, genital sores, or decreased libido Dysuria (pain when urinating) Docturia Hematuria (blood in urine) Urinary frequency Urinary hesitancy Penile discharge Genital sores Decreased libido Sexually active Trouble getting or keeping erections Pain or lump in testicles or scrotum Monthly testicular exam New sex partner last 12 months Prefer male Prefer female No preference History of sexual abuse

You can simply check yes on this line if no GU complaints

See HPI

Current

Mens Health Section

Comments

Yes

No

See HPI

Current

Yes

No

Musculoskeletal

Denies back pain, joint pain, joint swelling, muscle cramps, muscle weakness, stiffness Back pain Joint pain Joint swelling Muscle cramps Muscle weakness Stiffness

You can simply check yes on this line if no musculoskeletal complaints

Skin

Denies rash, itching, ulcers/growths, excess scarring, bleeding problem, dryness, suspicious lesions Rash Itching Ulcers/growths Excess scarring Bleeding problem Dryness Suspicious lesions Acne

You can simply check yes on this line if no skin complaints

Neurological Current

Denies transient paralysis, weakness, paresthesias, seizures, syncope, tremors, vertigo Headaches Syncope Seizures Weakness Paresthesias Transient paralysis Vertigo Tremors

You can simply check yes on this line if no neurological complaints

See HPI

Yes

Condition

Comments

No

See HPI

Current

Condition

Comments

Yes

No

See HPI

Current

Condition

Comments

Yes

No

Emotional and Cognitive

Condition Denies depression, anxiety, memory loss, mental disturbance, suicidal ideation, hallucinations, paranoia Depression Anxiety Memory loss Suicidal ideation Hallucinations Paranoia Mental disturbance Insomnia History of hospitalization for psychiatric problems

Comments You can simply check yes on this line if no mental health complaints

Endocrine

Hormonal Health

Comments

Denies cold intolerance, heat intolerance, polydipsia, polyphagia, polyuria, weight change, or hot flashes Polydipsia (excessive thirst) Polyphagia (excessive eating) Polyuria (excessive urination) Weight change Cold intolerance Heat intolerance Alopecia (hair loss) Hot flashes or night sweats Amenorrhea (women only-absence of period) Irregular menses (women only) Menorrhagia (women heavy bleeding) Change in menstrual pattern (women) Pain during intercourse History of uterine, cervical, vaginal, or ovarian problems (women, if yes please) Seeking pregnancy in next year (women, if yes are you on vitamins?) Fatigue Loss of libido (interest in sex) Loss of ability to have orgasm Inability to achieve or keep erection Poor exercise tolerance or decrease response to exercise

You can simply check yes on this line if no endocrine complaints

See HPI

Current

Yes

No

See HPI

Current

Yes

No

Heme/Lymphatic/Breast

Condition

Comments You can simply check yes on this line if no heme/lymph/breast complaints

Denies abnormal bruising, bleeding, enlarged lymph nodes, anemia Abnormal bruising Bleeding Enlarged lymph nodes History of anemia Lower extremity lymphedema Lipedema Breast lumps Breast tenderness Drainage from nipple Monthly breast exam

Allergic/Immunologic

Condition

Comments You can simply check yes on this line if no allergic/immunologic complaints

Denies urticaria, hay fever, persistent infections, HIV exposure Urticaria Hay fever Persistent infections HIV exposure

Health Screening See HPI

Current

Condition Reports Colonoscopy in past year Reports Mammogram in last year, Pap Smear in last year Men: Report Prostrate exam if appropriate for age and race Colonoscopy in past year (over 50) Returned hemoccult cards and neg for blood in past year Hemoccult cards given today Mammogram in last year (over 40) Fasting Blood Sugar Pap Smear

Comments You can simply check yes on this line if up to date with all of your currently recommended preventive health practices

Yes

No

See HPI

Current

Yes

No

See HPI

Current

Yes

No

Yes

Condition

Comments

Digital Rectal Exam (over 50) Lipid profile Thyroid lab TSH women over 40 and men over 50 BMD DXA scan ECG baseline over 50 Pneumovax at 60 Flu vaccine this year Diabetic patient has done eye exam, foot exam, urine dip, and at least 2 blood draws in past year, otherwise exercise counseling, and dietary education within 3 months.. Smoking activity assessed and cessation recommended if current smoker Cardio Exercise of at least 30 min 4 times a week Weight lifting 2-3 times a week

Social

Condition Recent changes in your life Satisfied with current living arrangement Satisfied with current employment Adequate income

Comments

Clinical research trial opportunities are available in our practice. Would you or anyone you know be interested in participating in a research study in any of the following areas? Reques t Info

Areas

Yes

No

Diabetes Treatment Diabetic Care after Heart Attack or Stent Fibromyalgia Treatment in Adolescents Fibromyalgia Treatment in Adults Chi Gong for treatment of different disease states Attention Deficit Disorder Treatment Chronic Pain New Treatment

Any other concerns you wish to discuss (describe)?

Reviewed by: ____________________________________

Date: ____________________

See HPI

Current

Yes

No

See HPI

Current

No