ADD - New Patient Information

***Patient privacy disclaimer*** The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of Stanford Owen, M.D. If the content of this form reaches you and you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. If you have received this transmission in error, please notify us immediately at (228) 864-9669 or drowenmd@drdiet.com.

How did you hear about us?

Name

First NameMiddle NameLast Name

Date of Birth

Date

SSN #

Age

Sex:

Marital Status

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Email

example@example.com

Employer

Work Phone Number

Area CodePhone Number

Emergency Contact

Emergency Contact Number

Area CodePhone Number

Relation to patient

Height

Weight

Major Complaint

Referred by

Name

First NameMiddle NameLast Name

Date of Birth

Date

SSN #

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Drivers License # and State

Employer

Work Phone Number

Area CodePhone Number

Parent/Guardian Signature

Present Height

Present Weight

Minimum Adult Weight

Maximum Adult Weight

Ideal Weight (if applicable)

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

Have you had any of the following?

Diabetes

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?

Frequent or constant headache

Fainting spells, convulsions

Dizziness

Loss of Hearing

Change of Vision

Dental Trouble

Bleeding Gums

Lumps on the Neck

Chest Pain

Shortness of Breath

Chronic Cough

Sputum

Cramps in Legs

Varicose Veins

Phlebitis (inflamed leg veins)

Swelling of Legs/Ankles

Rapid/Irregular Heartbeat

Comments

Indigestion or Heartburn

Nausea

Vomiting Blood

Pain/Abdominal Cramps

Diarrhea

Black Diarrhea

Bloody Diarrhea

Constipation

Average number of bowel movements per day

Average number of bowel movements per week

Daytime sleepiness

Insomnia

Normal sleep (average 6-8 hours)

Always hot

Always cold

Excessive Hair

Loss of Hair

Skin Texture (problems)

Have you ever had a reaction to any of the following:

Milk or dairy products

Eggs

Drugs or Medications

Comments

Do you consider yourself an active person?

Do you walk a mile or more per day?

Do you exercise on a regular basis?

If so, what type?

How often?

Comments

Pain

Incontinence

Frequent Night Time Urination

Impotence

Menstrual discharge

Pain during intercourse

Normal cycle

Other

Vaginal dryness

Unusual complications

Lumps on breast

Discharge from nipple

Excessive discomfort

Last Menstrual Date

Date

Last Gynecological Exam

Date

Pregnancies

Full Term Live

Caesareans

Miscarriage/Abortion

Complications

Stillbirth

Comments

Joint Pain

Back Pain

Swelling

Comments

Do you ever use the following?

Tobacco

Coffee

Alcohol

Tea

Comments

Do you have diabetes?

If so, for how long?

Do you check your blood sugar?

How often?

Do you take insulin?

Do you take medications?

Do you have numbness, tingling, or burning in feet?

Do you ever have hypoglycemia or low blood sugars (less than 70)?

How often? ___/week?

How do you treat?

Do you have any allergies?

Please list current medications and dosage

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

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

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

Rows	Yes	No
...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?

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?

Has a health professional ever told you that you have a manic-depressive illness or bipolar disorder?

Patient Signature

Heartburn

	1	2	3	4	5	6	7	8	9	10