*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

MaleFemalePrefer not to sayOther
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

SpouseRelativeFriendOther
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?

2-4x a day1x a day1 x every other dayLess than 1x every other day
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

Point Scale
*Rate each of the following symptoms based on your typical health profile.
0—Never or almost never have the symptom
1—Occasional, effect is not severe
2—Occasional, effect is severe
3—Frequent, effect is not severe
4—Frequent, effect is severe
Head
Headaches/Migraines
Faintness
Troubles Sleeping
Dizziness
Head
Head/Eyes
Watery Or Itchy Eyes
Swollen, Reddened, or Sticky Eyelids
Bags or Dark Circles Under Eyes
Blurred Or Tunnel Vision
Head/Eyes
Ears
Itchy Ears
Earaches, Ear Infections
Drainage From Ear
Ringing in Ears, Hearing Loss
Ears
Nose
Stuffy Nose
Sinus Problems
Hay Fever
Sneezing Attacks
Excessive Mucuous Formation
Nose
Skin
Acne
Hives, Rashes, Dry Skin
Hair Loss, Increased Facial/Body Hair
Flushing, Hot Flashes
Excessive Sweating
Skin
Heart
Chest Pain
Irregular or Skipped Heartbeat
Rapid or Pounding Heartbeat
Heart
Lungs
Chest Congestion
Asthma, Bronchitis
Shortness of Breath
Difficulty Breathing
Lungs
Other
Frequent Illness
Frequent or Urgent Urination
Genital Itch or Discharge
Interest in Having Sex in Low/Unable
Urge to Urinate Several Times a Night
Urge to Urinate Several Times a Day
Other
Digestive Tract
Nausea, Vomiting
Diarrhea
Constipation
Bloated Feeling
Belching, Passing Gas
Heartburn
Intestinal/Stomach Pain
Digestive Tract
Joints/Muscles
Pain or Aches in Joints
Arthiritis
Stiffness/Limitation of Movement
Feeling of weakness of tiredness
Pain or aches in the muscles
Joints/Muscles
Weight
Binge Eating/Drinking
Craving Certain Foods
Excessive Weight
Water Retention
Underweight
Compulsive Eating
Weights
Energy/Activity
Fatigue, Sluggishness
Apathy, Lethargy
Hyperactivity
Restlessness
Energy/Activity
Mind
Poor Memory
Confusion, Poor Comprehension
Difficulty in Making Decisions
Stuttering or Stammering
Slurred Speech
Learning Disabilities
Poor Concentration
Mind
Emotions
Mood Swings
Anxiety, Fear, Nervousness
Depression
Emotions
Menstruating Women Only
Premenstrual Symptoms
Cramping or Pain During Period
Absence of Periods
Periods Occur Irregular
Prolonged/Heavy Flow During Period
Menstruating Women Only
All Women
Vaginal Dryness
Sexual Intercourse is Uncomfortable
Breast Tenderness/Soreness
All Women
Grand Total

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 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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Confidential Patient Information

Personal Information

Emergency Contact

Physicians

Personal Wellness Goals and Social History

Dietary Habits

Diabetics Only

Point Scale

Head

Head/Eyes

Ears

Nose

Skin

Heart

Lungs

Other

Digestive Tract

Joints/Muscles

Weight

Energy/Activity

Mind

Emotions

Menstruating Women Only

All Women

Adult Illness(es):

Surger(ies)

Dental History

All Females Only: OB/GYN

Women in Menopause ONLY

Consent to Exam/Consultation

For Guardians Only: