• renew total body wellness center

    Thomas W. Rohde, M.D.

    New Patient Registration & Health History

  • New Patient Registration

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  • Birth Date*
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  • Gender*
  • Work Status*
  • Is this related to a work injury?*
  • Student Status*
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  • Person Responsible for Payment

    Please complete this section ONLY if NOT the same as patient.
  • Birth Date
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  • Financial and Patient Payment Policy

  • Renew Total Body Wellness Center requires a security deposit of $300 to secure your initial appointment with Dr. Rohde. This payment will be applied to any money owed at the time of your visit.

    Please note: we will require payment at the time your appointment is scheduled and confirmed.

    In the event you are a "No Show" or do not give 48 hours notice of cancellation, this fee will be forfeit. If you cancel more than 48 prior to your appointment time, we will refund this reservation fee.

    You can view our full Payment/Financial Policy document at the bottom of this form.

    If you have any questions about this policy, please contact our office at 217-864-2700 or helprenewme@gmail.com.

  • I understand and agree to the terms outlined above. 

  • Patient Health History

    Please answer the following questions as completely as possible. Answers are not required for every field; if a question is not applicable to you, you may leave that answer field blank.
  • Is your job stressful?
  • Is your job enjoyable?
  • Is your job fulfilling?
  • Are you exposed to hazardous materials?
  • When did you retire?
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  • Are you happy in retirement?

  • Health History Continued:

    Please answer the following questions as completely as possible. Answers are not required for every field; if a question is not applicable to you, you may leave that answer field blank.
  • Conditions (Check all that apply):*

  • Current or Recent Symptoms:*

  • Hospitalizations

    Please include surgeries, illnesses, severe accidents, births, miscarriages, etc.

  • Family History

    Please include all immediate family members, including father, mother, and siblings as appropriate.

  • Please indicate which, if any, of your blood relatives suffered from any of the following conditions:

  • Recent Testing

    Please indicate if you have had any of the following tests including the date of each, reason for testing, and the result.
  • Rows

  • Habits

    Please indicate which substances you consume, including frequency for each.
  • Rows

  • Women's Health

    Please answer the following questions as completely as possible. Answers are not required for every field; if a question is not applicable to you, you may leave that answer field blank.
  • Date of the 1st day of your last period:
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  • Have you ever used hormonal birth control?
  • Are you currently pregnant?
  • Date of last PAP test:
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  • Have you ever had an abnormal PAP test?
  • If yes, when?
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  • Date of last mammogram?
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  • Mammogram result?
  • Date of Menopause:
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  • Have you had a bone density scan?
  • Review this list of symptoms and check all that apply:

  • Men's Health

    Please answer the following questions as completely as possible. Answers are not required for every field; if a question is not applicable to you, you may leave that answer field blank.
  • Date of last prostate exam:
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  • Prostate exam result:
  • Date of last PSA test:
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  • Are you sexually active?
  • Do you now, or have you in the past, had a sexually transmitted disease?
  • Review this list of symptoms and check any that apply:

  • Biological Systems

    Please review the following symptoms and check any that apply.
  • Thyroid Symptoms:*
  • Adrenal Symptoms:*
  • Cardio-Respiratory Symptoms:*
  • Metabolism Symptoms:*
  • Skin / Integumentary Symptoms:*
  • Neuro-cognitive Symptoms:*
  • Gastrointestinal Symptoms:*
  • Muscles / Joints Symptoms:*

  • Diet:

  • Has this diet been successful?
  • Are you happy with your current weight?*

  • Stress:

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  • Where does your stress originate?
  • Do you have a solution?
  • Do you need help?

  • Exercise:

  • Please indicate which activities you participate in:*

  • Sleep:

  • Check any that apply:*

  • Take a moment to reflect on your response to the final question.

    On a scale of 0-5 (5 being the strongest response), please indicate your answer.
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  • Should be Empty: