ADD Clinics

New Patient Information
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General Information
Name

First Name Middle Name Last Name
Date of Birth

Month Day Year
Date
SSN #
Age
Sex:

Female Male
Marital Status
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Email
example@example.com
Employer
Work Phone Number

Area Code Phone Number
Emergency Contact
Emergency Contact Number

Area Code Phone Number
Relation to patient
Height
Weight
Major Complaint
Referred by
Responsible Party
Name

First Name Middle Name Last Name
Date of Birth

Month Day Year
Date
SSN #
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Drivers License # and State
Employer
Work Phone Number

Area Code Phone Number
Parent/Guardian Signature

Clear
Health History
Present Height
Present Weight
Minimum Adult Weight
Maximum Adult Weight
Ideal Weight (if applicable)
Family History
Has anyone in your family had any of the following? If positive, indicate mother/father/brother/sister/child/maternal/paternal
Obesity
Diabetes
Stroke
Heart Disease
Arthritis
Cancer
Patient-Medical
Have you had any of the following?

Pneumonia Tuberculosis Rheumatic Fever Heart Disease Coronary Disease High Blood Pressure Kidney Disease Ulcer Disease Anemia Kidney Stones Bowel Disease Gout Asthma Arthritis Gallstones Seizure Convulsions
Diabetes

Borderline Chemical Juvenile Onset Adult Onset
If so, when?
Surgeries
Hospitalizations
Serious Illness not needing hospitalizations (include reasons, diagnosis, and date)
Are you presently undergoing treatment for emotional or psychological problems?
Have you ever been hospitalized for psychological problems?
HEENT

Please select Yes or No
Frequent or constant headache

Yes No
Fainting spells, convulsions

Yes No
Dizziness

Yes No
Loss of Hearing

Yes No
Change of Vision

Yes No
Dental Trouble

Yes No
Bleeding Gums

Yes No
Lumps on the Neck

Yes No
Cardio-Respiratory

Please select Yes or No
Chest Pain

Yes No
Shortness of Breath

Yes No
Chronic Cough

Yes No
Sputum

Yes No
Cramps in Legs

Yes No
Varicose Veins

Yes No
Phlebitis (inflamed leg veins)

Yes No
Swelling of Legs/Ankles

Yes No
Rapid/Irregular Heartbeat

Yes No
Comments
Gastro-Intestinal

Please select Yes or No
Indigestion or Heartburn

Yes No
Nausea

Yes No
Vomiting Blood

Yes No
Pain/Abdominal Cramps

Yes No
Diarrhea

Yes No
Black Diarrhea

Yes No
Bloody Diarrhea

Yes No
Constipation

Yes No
Average number of bowel movements per day
Average number of bowel movements per week
Other
Daytime sleepiness

Yes No
Insomnia

Yes No
Normal sleep (average 6-8 hours)

Yes No
Always hot

Yes No
Always cold

Yes No
Excessive Hair

Yes No
Loss of Hair

Yes No
Skin Texture (problems)

Yes No
Have you ever had a reaction to any of the following:
Milk or dairy products

Yes No
Eggs

Yes No
Drugs or Medications

Yes No
Comments
Physical Activity
Do you consider yourself an active person?

Yes No
Do you walk a mile or more per day?

Yes No
Do you exercise on a regular basis?

Yes No
If so, what type?
How often?
Comments
Urinary
Pain

Yes No
Incontinence

Yes No
Frequent Night Time Urination

Yes No
Reproduction (men only)
Impotence

Yes No
Reproduction (women only)
Menstrual discharge

Yes No
Pain during intercourse

Yes No
Normal cycle

Yes No
Vaginal dryness

Yes No
Unusual complications

Yes No
Lumps on breast

Yes No
Discharge from nipple

Yes No
Excessive discomfort

Yes No
Last Menstrual Date

Month Day Year
Date
Last Gynecological Exam

Month Day Year
Date
Pregnancies
Full Term Live

Yes No
Caesareans

Yes No
Miscarriage/Abortion

Yes No
Complications

Yes No
Stillbirth

Yes No
Comments
Musculo-Skeletal
Joint Pain

Yes No
Back Pain

Yes No
Swelling

Yes No
Comments
Do you ever use the following?
Tobacco

Yes No
Coffee

Yes No
Alcohol

Yes No
Tea

Yes No
Comments
Diabetes
Do you have diabetes?

Yes No
If so, for how long?
Do you check your blood sugar?

Yes No
How often?
Do you take insulin?

Yes No
Do you take medications?

Yes No
Do you have numbness, tingling, or burning in feet?

Yes No
Do you ever have hypoglycemia or low blood sugars (less than 70)?

Yes No
How often? ___/week?
How do you treat?
Allergies
Do you have any allergies?
Medications
Please list current medications and dosage
Dr. Diet Psychological Profile

(Score as pertains to most days)

Depression

	1	2	3	4	5	6	7	8	9	10

1 is Never, 10 is Suicidal Thoughts

Anxiety

	1	2	3	4	5	6	7	8	9	10

1 is Never, 10 is Constant

Joy

	1	2	3	4	5	6	7	8	9	10

1 is Never, 10 is Always

Motivation/Energy

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is High

Libido (sex drive)

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is High

Sleep

	1	2	3	4	5	6	7	8	9	10

1 is Never sleep well, 10 is Perfect sleep

Eating Inventory

(for patients interested in nutrition therapy)
CASH Scale: Compulsions or Cravings/Appetite/Satiety/Hunger

Each feeling represents a different part of the brain and different neurotransmitters.

Compulsions/Cravings - A feeling or urge to eat when not hungry, often associated with other emotions such as "stress eating". You want food. There is no food in sight. You get an urge to eat which cannot be repressed.

	1	2	3	4	5	6	7	8	9	10

1 is Never Occurs, 10 is Constant

Appetite - A feeling of hunger stimulated by sight, sounds, smells, or social cues. You recently ate and feel full. You walk into a room and there is food everywhere. It looks and smells good, and everyone is having fun. You:

	1	2	3	4	5	6	7	8	9	10

1 is Never Eat, 10 is Always Eat

Satiety - A feeling of fullness acquired during eating. When you eat you usually:

	1	2	3	4	5	6	7	8	9	10

1 is One Plate Always, 10 is Second or third servings

Hunger - That feeling of a true pain or ache in your stomach when really empty. This is a true pain or discomfort.

	1	2	3	4	5	6	7	8	9	10

1 is Never Hungry, 10 is Constantly Hungry

Mood Disorder Questionnaire

Has there ever been a period of time when you were not your usual self and...

Yes

...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper you got in trouble?

...you were so irritable that you shouted at people or started fights or arguments?

...you felt much more self-confident than usual?

...you got much less sleep than usual and found that you didn't really miss it?

...you were more talkative or spoke much faster than usual?

...your thoughts raced through your head and you couldn't slow your mind down?

...you were so easily distracted by things around you that you had trouble concentrating or staying on track?

...you had much more energy than usual?

...you were much more active or did many more things than usual?

...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

...you were much more interested in sex than usual?

...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

...your spending money got you or your family in trouble?

If you checked YES to more than one fo the above, have several of these every happened during the same period of time?

Yes No

How much of a problem did any of these cause you- like being able to work; having family, money, or legal trouble; getting into arguments or fights?

	1	2	3	4	5

1 is No Problem, 5 is Serious Problem

Have any of your blood relatives (children, siblings, parents, grandparents, aunts, uncles) had a manic-depressive illness or bipolar disorder?

Yes No
Has a health professional ever told you that you have a manic-depressive illness or bipolar disorder?

Yes No
Patient Signature

Clear
Symptom Score Sheet

Please rate your symptoms below

Heartburn

	1	2	3	4	5	6	7	8	9	10