New Patient Registration Form

Today's Date

MonthDayYear

Referred By:

Name

First NameMiddle NameLast Name

E-mail

Contact Number:

Area CodePhone Number

Date of Birth

MonthDayYear

Height (inches)

Weight (pounds)

Marital Status

Number of Children

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

1. Complaints

Please rank your current complaints and rate their severity (on a scale of 1 to 10, 10 being the most severe)

2. Please tell us any additional information or concerns about your health

3. Medications

Please list any medications you are currently taking and how long you have taken them (including birth control pills, aspirin, pain medications, etc.)

4. Smoking

Do you currently smoke?

If yes, how much?

If yes, how long have you smoked?

5. Surgeries

What surgeries, operations, traumas, car accidents, etc. have you had?

a.) Have you ever had full-body anesthesia (i.e. to remove tonsils, widom teeth, etc.)?

b.) Do you have breast implants?

Other surgical implants or prostheses?

6. Stress

Please rate your current stress level (on a scale of 1 to 10, 10 being the highest stress):

What is the main reason(s) for your stress?

If over level 5, what step(s) are you taking to reduce your stress level?

7. Dental work

Indicate how many of the following you have:

Have you had any teeth extracted (widsom teeth, four bicuspid extraction etc.)?

Do you need further dental work? If so, what?

Health Overview

For the following questions, check the phrases that apply to you.

1. Sleep

How is your sleep?

Any complaints?

What time do you usually go to sleep?

Number of hours of sleep per night?

2. Digestion

How is your digestion?

Any complaints?

3. Urination

How are your daily urinations?

Any complaints?

4. Bowels

How are your bowel eliminations? How Often?

6. Exercise

What kind of exercise do you do?

How often?

5. Women Only

Are you pregnant?

Are you breast-feeding?

Do you have monthly periods?

Date of last menstrual period?

MonthDayYear

Are you going through menopause?

Have your periods stopped?

Have you had a hysterectomy?

(If so, when?)

MonthDayYear

Menstrual Cycle

Are your monthly periods regular (28 day cycles)?

Number of days of your menstrual flow?

Do you experience any of the following symptoms associated with your period?

Any menstrual complaints?

Y.M.I. is a 501-c-3, non-profit, educational organization dedicated to teaching and spreading the wisdom of natural healing.

Disclaimer: These statements have not been evaluated by the Food and Drug Administration. None of this information is meant to diagnose, treat, cure or prevent any medical conditions or disease. Ayurveda is a spiritual tradition of wellness and longevity meant to educate about foods, including herbs and supplements, and about meditation. This information is not meant to replace or in any way substitute for medical advice. For medical advice consult a licensed medical physician.

First Time Evaluation