FORM #4: Carolina Thermascan Medical Consultation Registration and Health History Form

Carolina Thermascan Medical Consultation 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?

YesNo
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:

YES - I have a Primary Care ProviderI do not have a primary care provider and acknowledge that the medical staff of the Carolina Center are not acting in the capacity of a PCP
Primary Care Provider if you have one

First NameLast Name
City and State
Please indicate which type of office visit you prefer:

Thermal Imaging Medical Consultation ($192) - Raleigh in personThermal Imaging Medical Consutlation ($192) - Wilmington in personThermal Imaging Medical Consultation ($192) - Virtual Telehealth
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.

Cancelof
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?

YesNoRegistered to attend
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*

ExcellentGoodFairPoor
Describe Your Body Shape*

HeavyMediumSmall
Describe Your Body Mass*

LeanPudgyObeseMuscularOut of Shape
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?*

YesNo
Have you ever had trouble getting IVs started in your arm?*

YesNo
Are you currently undergoing any treatment for your condition?*

YesNo
Brief History of this Condition:*
Have you previously been treated for any other conditions?*

YesNo
What types of therapies have you previously used in the treatment of your condition?*
Was it effective?*

YesNo
Please note any other major health or medical problems of which you are aware*
Have you had any lab tests within last 6 months?*

YesNo
Please list test name(s), date(s) and results.*
Do you currently take any medications?*

YesNo
Current Medications*
Do you currently take any vitamins or supplements?*

YesNo
Current Vitamins/Supplements*
Do you have any Allergies/Adverse Reactions or Side Effects to Medications?*

YesNo
List Allergies/Adverse Reactions and Side Effects to Medications*
Do you have any Allergies/Adverse Reactions or Side Effects to Chemicals?*

YesNo
List Allergies/Adverse Reactions and Side Effects to Chemicals*
Do you have any Allergies/Adverse Reactions or Side Effects to Foods?*

YesNo
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.*

Glasses/ContactsCataractsNear/Far SightedGlaucomaBlurred VisionDouble VisionEye InfectionEye PainChange in VisionNone of theseOther
Hearing/Ears You MUST check at least one option before you submit this form.*

Tinnitus (Ringing in ears)Hearing LossFrequent Ear Infections/AchesPrevious injury to the earsRecurrent Vertigo (Dizziness)Discharge from EarsFamily/Friends noting you having hearing problemsNone of theseOther
Respiratory/Breathing You MUST check at least one option before you submit this form.*

Sinus InfectionHay FeverEmphysemaPneumoniaNose BleedsHead ColdsLoss/Change os smell or tasteHoarsenessSore ThroatSores in Mouth or ThroatChronic CoughCoughing up BloodWaking at Night Short of BreathAllergiesTuberculosisAsthmaNone of theseOther
Heart/Circulation You MUST check at least one option before you submit this form.*

Rheumatic Fever, Rheumatic Heart DiseaseHigh Blood PressureAngina, Heart PainsHeart DiseaseChest PainPain radiating into your arms, neck, jaw or shouldersAble to lie flat on your back in bedVaricose VeinsPalpitations/Fluttering of HeartSwelling of Head, Feet or AnklesLeg Cramps while WalkingLeg Cramps at NightShortness of Breath after WalkingHeart AttackHeart MurmurStrokeAneurysmAbnormal EKGHigh CholesterolPeripheral Vascular Disease (Poor Circulation)None of theseOther
Digestive System You MUST check at least one option before you submit this form.*

Gallbladder ProblemsIndigestion/HeartburnHemorrhoidsPancreatitisColon polypsRepeated Stomach PainGum ProblemsBelchingChange in AppetiteNausea/VomitingDifficulty SwallowingConstipationBlack StoolsBloody StoolsDiarrhea (longer than 2-3 days)Liver DiseaseAbnormal Liver Function TestsUlcer - type detailsHernias - type detailsColitis - type detailsNone of theseOther
Kidney/Bladder You MUST check at least one option before you submit this form.*

GlomerulonephritisUrethritisKidney StonesFrequent Bladder InfectionsKidney infection/pyelonephritisPainful UrinationDifficulty Starting UrinationFrequency/Urgency of UrinationIncontinence (Involuntary loss of urine)Blood in UrineNone of theseOther
Orthopedics/Bones You MUST check at least one option before you submit this form.*

Neck Pain or SurgeryLow Back Pain or SurgeryLoss of an ExtremityJoint Aches/SurgeryJoint SwellingTingling/WeaknessMuscle SpasmsNumbness in Hands/FeetTrembling of Hands/FeetRecent Fracture - which bone(s)?Problems Walking/RunningRepeated Injuries to Same AreaArthritisNone of theseOther
Endocrine/Glands You MUST check at least one option before you submit this form.*

Hypothyroid (Low thyroid)Hyperthyroid (High thyroid)DiabetesHypoglycemia (Low blood sugar)Swollen GlandsSwollen Lymph NodesLump in ThroatIncreased ThirstIncreased UrinationUnintentional Weight LossUnintentional Weight GainDecreased Tolerance to ColdDecreased Tolerance to HeatChange in Texture of HairExcessive FatigueDischarge from NipplesNone of theseOther
Blood System You MUST check at least one option before you submit this form.*

AnemiaBleeding disorderAbnormal HemoglobinNone of theseOther
Neurological/Nerves You MUST check at least one option before you submit this form.*

Seizure disorder/EpilepsyRecurrent VertigoBell's PalsyNeuritis/Inflammation of a NervePinched NerveFrequent HeadachesSevere HeadachesDizzinessUnconscious SpellsInsomnia/Difficulty SleepingNervouse "Tics"FaintingConcussionNone of theseOther
Psychological You MUST check at least one option before you submit this form.*

DepressionAnxietyAlcoholismSubstance AbuseNone of theseOther
Skin You MUST check at least one option before you submit this form.*

RashEasily BruisedUnusual/Changing MolesChronic Acne/EruptionsNone of theseOther
For Men's Reproductive Organs You MUST check at least one option before you submit this form.*

Discharge from PenisLump in TesticlesEnlarged ProstateTesticular Tumor/ProblemsIs Sex Entirely SatisfactoryIs Sex Entirely UnsatisfactoryProstatitisImpotenceVenereal DiseaseNone of theseOther
For Women's Reproductive Organs You MUST check at least one option before you submit this form.*

Change in Vaginal DischargeMenstrual Pain/DysmenorrheaIncreased Menstrual BleedingBreast Lump/DischargePrevious Abnormal PAP SmearUnexplained Skipped/Absent PeriodsPain or Bleeding with IntercourseSex is Entirely SatisfactorySex is Entirely UnsatisfactoryPelvic Inflammatory DiseaseVenereal DiseaseNone of theseOther
Last PAP Smear*
Number of Pregnancies*
Number of Live Births*
Have you had cancer?*

YesNo
Please describe: type, month and year of diagnosis and treatment*
Have you had any previous hospitalizations, surgeries or serious illnesses?*

YesNo
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?*

YesNo
What type and how often?*
Do you engage in any muscle strength or endurance exercise?*

YesNo
What type and how often?*
Do you engage in any flexibility or stretching exercise?*

YesNo
What type and how often?*
Do you have any special diet or food needs?*

YesNo
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?*

0-25%26-50%51-75%76-100%
What is your daily intake of fiber?*
Have you changed your diet since the development of your condition?*

YesNo
Describe changes*
Do you feel this change has improved your health?*

YesNo
Drug, Alcohol and Tobacco Usage
Use of recreational drugs*

Never1-3 Times a Week4-7 Times a Week8 or More Times a Week
How often do you drink beer?*

Never1-3 Times a Week4-7 Times a Week8 or More Times a Week
How often do you drink wine?*

Never1-3 Times a Week4-7 Times a Week8 or More Times a Week
How often do you drink hard liquor?*

Never1-3 Times a Week4-7 Times a Week8 or More Times a Week
Do you currently use any form of tobacco?*

YesNo, I never used tobaccoNo, but I used it in the past
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?*

NoYes, I am overweightYes, I am underweight
Current Weight*
Current Height*
Highest Previous Weight*
Weight 1 Year Ago*
Are you doing (have you done) anything to control your weight?*

YesNo
Explain your efforts*
Can you easily see the veins on your arms and legs?*

YesNo
Stress Management
How stressful do you consider your life to be?*

HighModerateSlightVery Relaxed
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
Should be Empty:

Carolina Thermascan Medical Consultation 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