New Patient Forms

New Patient Registration and Health History

You are not required to finish this form in one sitting. You have the option to save your progress by scrolling to the bottom and clicking "Save." Then, you will be prompted to create an account which will send you an email with a link to complete this form at your convenience. (If for some reason you do not receive the email with the link, please look in your spam folder.) This form must be completed BEFORE your initial office visit can be scheduled.
Our primary goal in your initial office visit is to review your health history since childhood, understanding the sequence of health care events of your life and how they may be linked, leading us to your current state of health. We will review this form and all records provided prior to your initial visit, this allowing us to have the greatest understanding of your condition. Previewing this prior to your appointment allows us more time to answer your questions and discuss treatment considerations during your appointment.
Name
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Sex
Birthday

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What condition do you hope to improve here?
Marital Status
Currently Employed?
Employer Name
As a specialty practice, we encourage patients to maintain a relationship with a Primary Care Provider (PCP). Please select one of the following options:
Primary Care Provider if you have one

First NameLast Name
City and State
Please indicate which type of office visit you prefer:
Please provide a copy or photo of your driver's license (front and back) or other official identification as required by the US Patriot act. Failure to provide these files will delay scheduling.

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Financial Obligation Statement

The services you are electing to receive imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full of any and all charges incurred. As a courtesy, we will verify any insurance coverage and bill your insurance carrier on your behalf with the exception of Medicare, Medicaid, and Blue Cross Blue Shield; however, you are ultimately responsible for the payment of your bill. Payment for all office visits, procedures and other services is expected at the time the service is provided. Payment is also due immediately upon receipt of any bill presented to cover any deductible or coinsurance as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your claim you will be obligated to pay your account balance in full. I authorize my insurer to pay any benefits directly to Carolina Center for Integrative Medicine. I also agree to pay the Carolina Center the full and entire amount of all bills incurred by me within 30 days of treatment or upon receipt of any amount due after payment has been made by my insurance carrier. I understand that I will be assessed interest of 15% on any unpaid balance after 30 days and this interest will continue to accrue until payment is made in full. I have read the above policy regarding my financial responsibility to the Carolina Center for providing services to me. I certify that the information provided is, to the best of my knowledge, true and accurate.
No Perfume-Scented Toiletries Policy

For everyone's sake, please be aware of our No Perfume-Scented Toiletries policy and refrain from wearing any perfume or scented toiletries while at the clinic. Non-compliance may result in you being asked to leave and being assessed a cancellation fee.I have read all the information on the Carolina Center website under “New Patients” and “How to Become a Patient” and understand these procedures.I have read the “Orientation Handbook” and understand this information. I am requesting to become a patient of the Carolina Center and understand that it is highly recommended that I attend the “Introduction to the Carolina Center” Group Orientation prior to my visit although this is not required. Please sign and date that you acknowledge this policy.
Signature
How did you learn about us?
Who can we thank for referring you to our practice?

First NameLast Name
New Patient Orientation

We greatly appreciate your interest in becoming a patient at the Carolina Center. In contrast with conventional medicine, integrative medicine involves an entirely different way of thinking about health and the body. The processes and procedures we follow are not always familiar to people. We need to obtain a great deal of information from you in order to provide the best care. There is also much you will need to learn from us. While optional, it is strongly recommended that all new patients attend one of our regularly scheduled “Introduction to the Carolina Center” group orientations. During this time you will meet Dr. Pittman and learn the basics of a cellular-based integrative approach and have your questions answered. If you were unable to attend the New Patient Orientation prior to your initial office visit we strongly encourage you to attend a session prior to your first follow-up office visit.
Have you attended new patient orientation?
Chronologic History of Health Events

(Events and Symptoms Grouped by Decades)

Please Include:
- Details about major illnesses, hospitalizations, surgeries, trauma, pregnancies, symptoms, etc.
- Details about frequency of infections and use of antibiotics
- Dental work other than routine cleanings, especially placement or removal of amalgam fillings
- Exposures to toxins, chemicals; history of work in potentially dangerous environments
Childhood:
Teens:
Twenties:
Thirties:
Forties:
Fifties:
Sixties:
Seventies:
Eighties and older:
Recent Medical Care
Last Physical Exam
Last Blood Work/Urinalysis
Last Blood Pressure Check
Last EKG (Electrocardiogram)
Last Chest X-ray
Other X-rays
Last Vision Check
Last Dental Check/Cleaning
Last Hearing Check
Last Stool Test for Bleeding
Last Colonoscopy
Present Health Status
Rate Your Present Health Status
Describe Your Body Shape
Describe Your Body Mass
Without special agreement and arrangements, we are unable to accommodate patients who are not ambulatory due to the extra staff necessary for assistance. If you are in a wheelchair and wish to be a patient, you will need someone to come to all sessions with you as an assistant. Are you able to walk without assistance?
Have you ever had trouble getting IVs started in your arm?
Are you currently undergoing any treatment for your condition?
Brief History of this Condition:
Have you previously been treated for any other conditions?
What types of therapies have you previously used in the treatment of your condition?
Was it effective?
Please note any other major health or medical problems of which you are aware
Have you had any lab tests within last 6 months?
Please list test name(s), date(s) and results.
Do you currently take any medications?
Current Medications
Do you currently take any vitamins or supplements?
Current Vitamins/Supplements
Do you have any Allergies/Adverse Reactions or Side Effects to Medications?
List Allergies/Adverse Reactions and Side Effects to Medications
Do you have any Allergies/Adverse Reactions or Side Effects to Chemicals?
List Allergies/Adverse Reactions and Side Effects to Chemicals
Do you have any Allergies/Adverse Reactions or Side Effects to Foods?
List Allergies/Adverse Reactions and Side Effects to Foods
Past Medical History

Do you now have or have you had any of the following symptoms within the past 12 months:
Eyes/Vision You MUST check at least one option before you submit this form.

Other
Hearing/Ears You MUST check at least one option before you submit this form.

Other
Respiratory/Breathing You MUST check at least one option before you submit this form.

Other
Heart/Circulation You MUST check at least one option before you submit this form.

Other
Digestive System You MUST check at least one option before you submit this form.

Other
Kidney/Bladder You MUST check at least one option before you submit this form.

Other
Orthopedics/Bones You MUST check at least one option before you submit this form.

Other
Endocrine/Glands You MUST check at least one option before you submit this form.

Other
Blood System You MUST check at least one option before you submit this form.

Other
Neurological/Nerves You MUST check at least one option before you submit this form.

Other
Psychological You MUST check at least one option before you submit this form.

Other
Skin You MUST check at least one option before you submit this form.

Other
For Men's Reproductive Organs You MUST check at least one option before you submit this form.

Other
For Women's Reproductive Organs You MUST check at least one option before you submit this form.

Other
Last PAP Smear
Number of Pregnancies
Number of Live Births
Have you had cancer?
Please describe: type, month and year of diagnosis and treatment
Have you had any previous hospitalizations, surgeries or serious illnesses?
Hospitalizations, Surgeries and Serious Illnesses

Major Family Illnesses: Has any relative had one or more of the following? Please check all that apply. You MUST check at least one option on each row before you can submit this form.

Rows	Heart Disease	High Blood Pressure	Stroke	High Cholesterol	Bowel/Colon Disorders (including Polyps)	Lung Disease	Unknown or N/A
Mother
Father
Sister
Brother
Aunt
Uncle
Spouse
Child(ren)
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Grandchild
Other

Major Family Illnesses Continued: Has any relative had one or more of the following? Please check all that apply. You MUST check at least one option on each row before you can submit this form.

Rows	Alcoholism	Glaucoma	Cancer	If "yes" to cancer, provide type	Diabetes	Unknown or N/A
Mother
Father
Sister
Brother
Aunt
Uncle
Spouse
Child(ren)
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Grandchild
Other

Family History: You MUST check at least one option on each row before you can submit this form.

Rows	Status of Health	Current Age or Age at Death	Major Illnesses or Cause of Death	Unknown or N/A
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandchild
Sister
Sister
Brother
Brother
Child
Child
Child
Other

Lifestyle & Nutrition
Do you engage in any cardiovascular or aerobic exercise?
What type and how often?
Do you engage in any muscle strength or endurance exercise?
What type and how often?
Do you engage in any flexibility or stretching exercise?
What type and how often?
Do you have any special diet or food needs?
Please list considerations.

Do you consume the following: You MUST check at least one option per row before you submit this form.

Rows	Yes/No	How Often	Favorite Type
Fish
Dairy
Fried Foods
Caffeinated Beverages

Describe your typical breakfast.
Describe your typical lunch.
Describe your typical dinner.
What percentage of your diet is raw & uncooked?
What is your daily intake of fiber?
Have you changed your diet since the development of your condition?
Describe changes
Do you feel this change has improved your health?
Drug, Alcohol and Tobacco Usage
Use of recreational drugs
How often do you drink beer?
How often do you drink wine?
How often do you drink hard liquor?
Do you currently use any form of tobacco?
What type and how much do you use?
List type(s) did you use and year(s) that you quit for each
Is Weight a Problem for You?
Current Weight
Current Height
Highest Previous Weight
Weight 1 Year Ago
Are you doing (have you done) anything to control your weight?
Explain your efforts
Can you easily see the veins on your arms and legs?
Stress Management
How stressful do you consider your life to be?
How many weeks of vacation do you take each year?

Relaxation/Leisure Activities You MUST check at least one option on each row before you submit this form.

Rows	Yes/No	How Often	How Long	Specific Type?
Do you meditate
Do you practice other relaxation exercise?
Do you have any regular or leisure time activities?

How many hours of sleep do you get each night?
What is the quality of your sleep?
I certify that the above information is true and correct to the best of my knowledge. By signing below I agree to all terms and conditions included in this registration and medical history form.

It is my responsibility to inform my physician if there are any changes in any of the information contained in this form.
Patient Signature
Date

MonthDayYear
Insurance Information
Please note that while Carolina Center does not accept Blue Cross/Shield, Medicare or Medicaid and can only file certain claims with other insurance carriers, we are able to utilize most major insurance for certain labs and prescriptions. PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD SO WE CAN HELP YOU FILE CLAIMS IF ABLE. Do you have health insurance?
Are you the policyholder on this primary insurance?
Front of primary insurance card.

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Back of primary insurance card.

Cancelof
If you have Medicare Prescription coverage, upload your Part D Prescription Benefits Card

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Subscriber's name
Birthdate of subscriber

MonthDayYear
Sex of subscriber
Relationship to patient
Are you the policyholder on this secondary insurance?
Front of secondary insurance card.

Cancelof
Back of secondary insurance card.

Cancelof
Subscriber's name
Birthdate of subscriber

MonthDayYear
Sex of subscriber
Relationship to patient
Emergency Contact Information
Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Information
Name of Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
HIPPA Privacy Authorization Form

Do you wish to authorize Carolina Center for Integrative Medicine to release any and all medical information and test results that pertain to you, to someone else?
Authorized Person

First NameLast Name
Email
example@example.com
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Signature
Should be Empty:

New Patient Registration and Health History

Financial Obligation Statement

No Perfume-Scented Toiletries Policy

New Patient Orientation

Chronologic History of Health Events

Recent Medical Care

Present Health Status

Past Medical History

Lifestyle & Nutrition

Drug, Alcohol and Tobacco Usage

Stress Management

Insurance Information

Emergency Contact Information

Pharmacy Information

HIPPA Privacy Authorization Form