Patient Forms

Registration
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale

Address*

Address

Street Address Line 2

CityState

Zip
Cell Phone*
Home Phone
Work Phone*
Email*
example@example.com
Marital Status*

MarriedSingleDivorcedWidowed
Occupation*
Employer*
If retired - Previous Occupation
Spouse's Name

First NameLast Name
Date of Birth

MonthDayYear
Occupation
Employer
If retired - Previous Occupation
Please provide insurance information for purposes of potential diagnostic tests and referrals. ICAM staff will make a photo copy of your insurance card - Thank you

Client Health History
Name*

First NameLast Name
Date*

MonthDayYear
Date of Birth*

MonthDayYear
Age*
Gender*

MaleFemale
Marital Status*

SingleMarriedDivorcedWidowed
How did you learn about ICAM*
Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally, and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank you.
Height*
Weight - Currently*
Weight - Past Maximum*
When?*
Pulse*
Blood Pressure*
Other
Primary Health Care Provider*
Other Specialists
What health concerns bring you to ICAM?*
1. Please identify the health concerns that have brought you to ICAM in order of importance below:
a. Condition*
a. Past Treatment*
a. How does this condition affect you?*
b. Condition
b. Past Treatment
b. How does this condition affect you?
c. Condition
c. Past Treatment
c. How does this condition affect you?
2. Please list any foods drugs or medications you are hypersensitive or allergic to please include reaction*
3. Please list any medications (prescribed and over-the-counter), vitamins and supplements you are currently taking including dosage and frequency per day*
Do you have any reason to believe you may be pregnant?*

YesNo

Past Pregancies


Age
Age
Age
Age

5. Do you have any infectious diseases?*

YesNo
If yes, please specify

6. Family History (Fill out all that apply)

	Father	Mother	Brother(s)	Sister(s)	Spouse	Children
Age (if living)
Health (G=Good, P=Poor)
Age (at death)
Cause of Death

Check all that apply*

	Father	Mother	Brother(s)	Sister(s)	Spouse	Children	N/A
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Mental Illness
Asthma/Hay Fever
Kidney Disease

Other
7. Childhood Illness (Please check any you have had in the past*

Scarlet FeverRheumatic FeverMumpsMeaslesGerman MeaslesChicken PoxNone of the above
Childhood Immunizations*

8. Emotional*

	Experience NOW	Have experienced in the PAST	N/A
Mood Swings
Nervousness
Mental Tension
Anxiety

9. Energy and Immunity*

	Experience NOW	Have experienced in the PAST	N/A
Fatigue
Slow wound healing
Chronic Infections
Chronic Fatigue Syndrome

10. Head, Eye, Ear, Nose, and Throat*

	Experience NOW	Have experienced in the PAST	N/A
Impaired Vision
Eye Pain/Strain
Glaucoma
Glasses/Contacts
Tearing/Dryness
Impaired Hearing
Ear Ringing
Earaches
Headaches
Sinus Problems
Nose Bleeds
Frequent Sore Throats
Teeth Grinding
TMJ Problems
Hay Fever

11. Respiratory*

	Experience NOW	Have experienced in the PAST	N/A
Pneumonia
Frequent Common Colds
Difficulty Breathing
Emphysema
Persistent Cough
Pleurisy
Asthma
Tuberculosis
Shortness of Breath

Other Respiratory Problems

12. Cardiovascular*

	Experience NOW	Have experienced in the PAST	N/A
Heart Disease
Chest Pain
Swelling Ankles
High Blood Pressure
Palpitations/Fluttering
Stroke
Heart Murmurs
Rheumatic Fever
Varicose Veins

13. Gastrointestinal*

	Experience NOW	Have experienced in the PAST	N/A
Ulcers
Changes in appetite
Nausea/Vomiting
Epigastric Pain
Passing Gas
Heartburn
Belching
Gall Bladder Disease
Liver Disease
Hepatitis B or C
Hemorrhoids
Abdominal Pain
Flatulence
Bloating

14. Genito-Urinary Tract*

	Experience NOW	Have experienced in the PAST	N/A
Kidney Disease
Painful Urination
Frequent UTI
Frequent Urination
Heavy Flow
Kidney Stones
Impaired Urination
Blood in Urine
Frequent Urination at night

15. Female Reproductive/Breasts*

	Experience NOW	Have experienced in the PAST	N/A
Irregular Cycles
Breast Lumps/Tenderness
Nipple Discharge
Heavy Flow
Vaginal Discharge
Premenstrual Problems
Clotting
Bleeding Between Cycles
Menopausal Symptoms
Difficulty Conceiving
Painful Periods

16. Male Reproductive*

	Experience NOW	Have experienced in the PAST	N/A
Sexual Difficulties
Prostate Problems
Testicular Pain/Swelling
Penile Discharge

17. Musculoskeletal*

	Experience NOW	Have experienced in the PAST	N/A
Neck/Shoulder Pain
Muscle Spasms/Cramps
Arm Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Leg Pain
Joint Pain

If yes to Joint Pain, where?

18. Neurologic*

	Experience NOW	Have experienced in the PAST	N/A
Vertigo/Dizziness
Paralysis
Numbness/Tingling
Loss of Balance
Seizures/Epilepsy

19. Endocrine*

	Experience NOW	Have experienced in the PAST	N/A
Hypoglycemia
Diabetes
Mellitus
Night Sweats
Feeling Hot or Cold

20. Other*

	Experience NOW	Have experienced in the PAST	N/A
Anemia
Cancer
Rashes
Eczema/Hives
Cold Hands/Feet

21. Dental Issues*

	YES	NO	Which teeth?
Do you have any silver (amalgam) fillings?
Do you have any root canals?
Do you have any implants
Have you had any extractions?

Is there anything else we should know?
22. Lifestyle
a. Do you typically eat at least three meals per day?*

YesNo
If no, how many?
b. Exercise Routine*
c. Spiritual Routine*
d. How many hours per night do you sleep?*
Do you wake rested?*

YesNo
Do you fall asleep quickly?*

YesNo
Do you sleep through the night?*

YesNo
e. Occupation*
Employer*
Hours/Week*
Do you enjoy work?*

YesNo
Why/Why not?*
f. Nicotine/Alcohol/Caffeine Use*
g. Have you experienced any physical or emotional traumas?*

YesNo
If yes, please explain
h. How much water do you drink per day?*
i. Do you have a bowel movement everyday?*

YesNo
23. Surgery/Hospitalizations with age*
24. Toxic profession/Exposure past or present*
25. Please list the location of any scars on your body with the date and reason for said scar*
26. Please write down any other information that you believe is important for us to know*

Diet History

Please complete for 3 days
Name*

First NameLast Name
DAY 1
Date*

MonthDayYear
Breakfast*
Lunch*
Dinner*
Snacks*
DAY 2
Date*

MonthDayYear
Breakfast*
Lunch*
Dinner*
Snacks*
DAY 3
Date*

MonthDayYear
Breakfast*
Lunch*
Dinner*
Snacks*

CONSENT TO TREAT:
The undersigned consents to receive integrated, complementary & alternative health care services provided by health care practitioners. Specific services may include diagnostic procedures, examinations, treatments, or other services rendered under the special instructions of the practitioners. The undersigned understands that treatment modalities offered at ICAM may differ from conventional allopathic medicine.
Signature*

Clear
Date*

MonthDayYear
Witness*
Date*

MonthDayYear
Note: Payment is expected at time of services rendered and is the responsibility of the client. Clients may submit charges to their insurance carrier, with the understanding that services may or may not be covered.
Should be Empty:

Registration

Client Health History

Diet History

DAY 1

DAY 2

DAY 3

CONSENT TO TREAT: