Evaluation Form

New patient evaluation form Welcome to my office. I look forward to meeting you and working with you. The more you can complete of this New Patient Form BEFORE our first meeting, the faster we can begin reaching solutions for you. Please just take a few minutes of your time. Please bring any current prescriptions with you to our meeting. Please also bring any medical records and lab work you have on hand, even if you think it doesn't apply to the solutions you are seeking with me. Please either scan this form and return it to me at DrCorona@DrPaulCoronaMD.com or bring it with you to the appointment.

Name*

First NameLast Name

Who referred you (if anyone) and what is the primary reason for you being here today?

What do you do for work (if you work), or where are you in school?

What are your hobbies? What do you do to relieve stress or just have fun?

List symptoms you suffer from such as headaches neck/shoulder/back pain, Fibromyalgia, Irritable Bowel Syndrome acid reflux, ulcers, high blood pressure, chest pain/tightness, difficulty breathing, skin problems or any other physical, sometimes chronic symptoms.

How is your sleep quality? If you have insomnia, how severe is it and for how long?

How is your daytime energy, motivation and drive?

Are you happy with your weight and level of physical fitness? If you work out, please give details.

Do you smoke? If so how much and for how long?

Do you drink? If so, how much and how often, on average? Do people who know you think it's a problem?

Have you seen psychologists and other counselors, primary care doctors, psychiatrists, alternative health-care providers or anyone else you are treated by regarding your emotional and physical health? If so give details.

Do you have a history of any medical problems? Give significant details, and bring any lab work and results of diagnostic studies that have been done, as well as consultation notes from any doctors or other health providers.

Tell me about any significant family history, especially regarding mood disorders, psychiatric hospitalizations, alcoholism or other addictions, or dysfunctional lives in general.

Describe any significant emotional symptoms, i.e., worry, rumination, obsessive thinking and behaviors, nervous habits, frequent sadness or crying, hopelessness, anger outbursts, apathy, difficulty with focus, mood swings.

List all significant medications you have taken, whether by prescription, by mail order/distributor or over the counter medications, vitamins, supplements, etc. Give as many details as possible regarding their dosages and how long they were taken.

What were the specific benefits and/or side effects?

Do you have any significant allergic history to medications, antibiotics, foods or other environmental allergens such as pollen, dust, pets, grasses?

Do you have any menstrual problems?

Is there a significant connection between your menstrual history as related to your moods (PMS)? If so, about how old were you when noticed the onset?

Are you pre menopausal or have you completed menopause? What are or were your symptoms?

When were the worst and best times of your life?

When did you feel yourself and when and how did that change?

What are the key goals you would like to achieve by my treatment with me?