ADD - New Patient Information

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?
General Information
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
SSN #
Age
Sex:

FemaleMale
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
Responsible Party
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
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

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?

PneumoniaTuberculosisRheumatic FeverHeart DiseaseCoronary DiseaseHigh Blood PressureKidney DiseaseUlcer DiseaseAnemiaKidney StonesBowel DiseaseGoutAsthmaArthritisGallstonesSeizureConvulsions
Diabetes

BorderlineChemicalJuvenile OnsetAdult 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

YesNo
Fainting spells, convulsions

YesNo
Dizziness

YesNo
Loss of Hearing

YesNo
Change of Vision

YesNo
Dental Trouble

YesNo
Bleeding Gums

YesNo
Lumps on the Neck

YesNo
Cardio-Respiratory

Please select Yes or No
Chest Pain

YesNo
Shortness of Breath

YesNo
Chronic Cough

YesNo
Sputum

YesNo
Cramps in Legs

YesNo
Varicose Veins

YesNo
Phlebitis (inflamed leg veins)

YesNo
Swelling of Legs/Ankles

YesNo
Rapid/Irregular Heartbeat

YesNo
Comments
Gastro-Intestinal

Please select Yes or No
Indigestion or Heartburn

YesNo
Nausea

YesNo
Vomiting Blood

YesNo
Pain/Abdominal Cramps

YesNo
Diarrhea

YesNo
Black Diarrhea

YesNo
Bloody Diarrhea

YesNo
Constipation

YesNo
Average number of bowel movements per day
Average number of bowel movements per week
Other
Daytime sleepiness

YesNo
Insomnia

YesNo
Normal sleep (average 6-8 hours)

YesNo
Always hot

YesNo
Always cold

YesNo
Excessive Hair

YesNo
Loss of Hair

YesNo
Skin Texture (problems)

YesNo
Have you ever had a reaction to any of the following:
Milk or dairy products

YesNo
Eggs

YesNo
Drugs or Medications

YesNo
Comments
Physical Activity
Do you consider yourself an active person?

YesNo
Do you walk a mile or more per day?

YesNo
Do you exercise on a regular basis?

YesNo
If so, what type?
How often?
Comments
Urinary
Pain

YesNo
Incontinence

YesNo
Frequent Night Time Urination

YesNo
Reproduction (men only)
Impotence

YesNo
Reproduction (women only)
Menstrual discharge

YesNo
Pain during intercourse

YesNo
Normal cycle

YesNoOther
Vaginal dryness

YesNo
Unusual complications

YesNo
Lumps on breast

YesNo
Discharge from nipple

YesNo
Excessive discomfort

YesNo
Last Menstrual Date

MonthDayYear
Date
Last Gynecological Exam

MonthDayYear
Date
Pregnancies
Full Term Live

YesNo
Caesareans

YesNo
Miscarriage/Abortion

YesNo
Complications

YesNo
Stillbirth

YesNo
Comments
Musculo-Skeletal
Joint Pain

YesNo
Back Pain

YesNo
Swelling

YesNo
Comments
Do you ever use the following?
Tobacco

YesNo
Coffee

YesNo
Alcohol

YesNo
Tea

YesNo
Comments
Diabetes
Do you have diabetes?

YesNo
If so, for how long?
Do you check your blood sugar?

YesNo
How often?
Do you take insulin?

YesNo
Do you take medications?

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

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

YesNo
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	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?

YesNo

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?

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

YesNo
Patient Signature

Clear
Symptom Score Sheet

Please rate your symptoms below

Heartburn

	1	2	3	4	5	6	7	8	9	10