*Confidential Patient Information

Confidential Patient Information
Personal Information
Title
First Name
Middle Name
Last Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Birth Date (You Can Use Numeric Key Pad To Enter Date)

MonthDayYear
Date
Age
Sex at Birth
Current Gender Identity if different from birth:
Email- Please use same email we sent the link to
Marital Status
Spouse's name or the name of who you live with if you consider them your partner
Do you have children? If yes, what are the ages of your children?
Ethnic Descent or Ancestry
Occupation/Job title
Work (hrs/week)
How was it that you were referred to our office? (Family, Friend, Facebook, Internet search, etc)
Emergency Contact
First Name
Last Name
Phone Number
Relationship
Physicians
Name of primary care physicians. If you are not under care answer NA.
Phone Number
Specialist or other doctors seen for your current health condition: If you have not seen any other doctor(s) answer NA.
Testing you have received for your current condition. Have you had an MRI, allergy test, stool testing, blood tests or any other test?

Personal Wellness Goals and Social History

Please list your chief symptoms or health goals, starting with the worst symptom or most important goal first.

Rows	Problem or Goal e.g. Headaches	Onset e.g. June 2007 or 21 yoa	Frequency e.g. 4 times per week	Severity e.g. Mild / moderate / severe
1
2
3
4

When was the last time you felt completely healthy?
What do you think happened that caused you to start to feel unhealthy or not 100%? (it could be emotional, it could be physical etc.
Besides your spouse, your kids, your parents and your job, what do you love, what is your passion, what is the one thing you enjoy the most to do?
Do you ever have headaches caused from smells? Do you have a heightened sense of smell? Do you have an allergy to sulfa based medications? Do you have any adverse reactions when you drink wine? Do smells cause an emotional response (irritability, nausea, dizziness)? Does your gas have a sulfur smell? Do you have a sulfur body odor? If yes to any of these please explain. If no please answer no.
How Often Do You Have Bowel Movements?
Please explain your bowel movements. What color and consistency are your bowel movements? Do they float or sink? Is it hard to pass a bowel movement? Do you have a sense of urgency?

Diabetics Only
I Am Not a Diabetic; skip to next section.
How Old Were You When You First Discovered You Were a Diabetic?
What is the Highest your blood sugar is WITHOUT medications:
What is the Highest your blood sugar is WITH medications:
What is the Lowest your blood sugar is WITHOUT medications:
What is the Lowest your blood sugar is WITH medication:
What is your A1C level? If unsure leave blank

Consent to Exam/Consultation
1. I hereby state that the information provided by me is accurate and whole.
2. I understand that the consultation/exam process does not guarantee that I will be accepted for treatment. The doctor may determine that there is a better course of care for me than what is available at Integrative Wellness Centers.
3. I understand that all my records and health information are protected, kept confidential and stored in a secure manner.
4. I give Integrative Wellness Centers permission to email me my test results.
5. I understand that I am allowed to request a copy of the privacy and patient rights policy of Integrative Wellness Centers.
6. I understand the care provided here is not to substitute the care of my primary care physician.
7. I understand that if I have Medicare, Medicaid, Champus, WPS, or TRICARE I hereby waive my rights to file a claim and seek reimbursement for services/testing performed through Integrative Wellness Centers.
8. I understand that Integrative Wellness Centers uses secure, HIPAA-compliant software systems — some of which incorporate artificial intelligence — to assist with clinical documentation, care/testing platforms, and lab result review. These systems operate under signed Business Associate Agreements that legally bind them to the same confidentiality and security standards required of Integrative Wellness Centers.
9. I have read, understand and accept the terms of the consent to exam/consultation.
Patient Print Name

First NameLast Name
Patient Signature
Date

MonthDayYear
Date
For Guardians Only:
Guardian Name Print for Authorizing Care:

First NameLast Name
Guardian's Signature of Authorizing Care
Date

MonthDayYear
Date
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