New Patient Paperwork

Patient Name
Date of Birth
How Long?
Reason for Visit
Severity? (1-10)
#1
#2
#3
Insurance Information
Company
ID number
Group Number
Plan Name
Is patient same as insured?
Do you have a secondary?
Are these complaints associated with...
An Auto Accident?
Company
Work Injury?
Claim Number
Employer
Accident Date & Location
Date
Personal Information
Male
Female
Phone
Email
Address
City, St.
Emergency Contact
Phone
Privacy Information:
I agree to the privacy practices of this office.
Initial:________
Medical Information (check all that apply)
Allergies
Skin Conditions
Asthma
Fatigue
Diarrhea
Constipation
Heartburn
Insomnia
Pregnant
Surgeries
Fractures
High Cholesterol
Diabetes
Hypertension
Cancer
Nausea
Vomiting
Blurring of Vision
Kidney Disease
Heart Disease
Menopause
Menstrual Issues
PMS
Headaches
Anemia
Chronic Pain
Arthritis
Weight Concerns
Patient Name
Medications
Name
Dosage
#1
#2
#3
Reason
#4
#5
Are there more?
Supplements, Herbs, Vitamins, etc. (please list)
Dietary Information (please try to list everything you ate or drank yesterday)
Breakfast
Lunch
Dinner
Other
Sleep Information
About how many hours of sleep do you get per night?
Cautions and Concerns
Is there any chance you are pregnant?
Do you have any electronic implants?
Do you have AIDS, Hepatitis, Diabetes, Lymphedema, or Cellulitis?
Anything else we should know?
Patient Name
Medical History (Please list any major surgeries including tonsils, gall bladder or appendix, illnesses, or
important medical events and the dates.)
Family Medical History (indicate any relations who suffered from cancers, heart disease, strokes,
auto-immune conditions or other significant illnesses.)
Current and Recent Medical Care
Who is your current primary care provider?
Practice Location?
Are you seeing any specialists? (please list)
Release Disclosure
In the interest of providing for the best possible coordination of care our office sends a
letter to patients’ primary care providers, informing them of our findings, treatment
modalities and goals of treatment. This also opens lines of communication ensuring that all
concerns are addressed. Do you give us permission to send your primary care physician a
report of our findings and treatment intentions?
Signature:
Any other providers you would like us to contact?
Date:
Patient Name
Multiple Symptom Questionnaire
Rate each of the following symptoms over the past 60 days.
Rating 0- Never or almost never have the
symptom
Scale
1- Occasionally have it, but not severe
2- Occasionally have it, and it is severe
3- Frequently have it, but it is not severe.
4- Frequently have it, and it is severe.
Head
Headaches
Skin
Acne
Faintness
Dizziness
Insomnia
Total for Section
Hives
Hair Loss
Flushing
Excessive Sweating
Eyes
Watery or Itchy eyes
Swollen, red or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not
include far-sightedness)
Total for Section
Nose
Stuffy nose
Sinus Problems
Hay Fever
Sneezing Attacks
Excessive Mucus Production
Total for Section
Total for Section
Heart
Irregular or skipped beats
Rapid or Pounding Heartbeat
Chest Pain
Total for Section
Lungs
Chest Congestion
Asthma, bronchitis
Shortness of Breath
Difficulty Breathing
Total for Section
Mouth and Throat
Chronic coughing
Gagging, frequent need to clear throat
Sore, hoarse throat, loss of voice
Discoloration or swelling of gums,
lips, tongue
Canker Sores
Digestive Tract
Nausea, Vomiting
Diarrhea
Constipation
Bloated Feeling
Belching, Passing gas
Heartburn, Reflux
Intestinal, Stomach Pain
Total for Section
Total for Section
Patient Name
Multiple Symptom Questionnaire Pg 2
Rate each of the following symptoms over the past 60 days.
Rating 0- Never or almost never have the
symptom
Scale
1- Occasionally have it, but not severe
2- Occasionally have it, and it is severe
3- Frequently have it, but it is not severe.
4- Frequently have it, and it is severe.
Joint/Muscles
Pain or aches in joints
Mental
Poor memory
Arthritis
Stiffness or limited movement
Pain or Aches in Muscles
Feeling of weakness or tiredness
Confusion, Poor Comprehension
Poor Concentration
Poor Physical Coordination
Total for Section
Weight
Binge eating/drinking
Craving certain foods
Excessive Weight
Compulsive Eating
Water Retention
Underweight
Difficulty Making Decisions
Stuttering or Stammering Speech
Slurred Speech
Learning Disabilities
Total for Section
Emotions
Mood Swings
Anxiety/fear/nervousness
Anger/irritability
Total for Section
Panic Attacks
Depression
Energy/Activity
Fatigue, tired, sluggish
Apathy, lethargy
Hyperactivity
Restlessness
Total for Section
Total for Section
Total for All Sections
Other
Frequent Illness
Frequent or Urgent Urination
Genital Itch or Discharge
Total for Section
Date