New Patient Registration Form

First Time Evaluation
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?

YesNo
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.)?

YesNo
b.) Do you have breast implants?

YesNo
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:
Indicate how many of the following you have:

Silver fillingsRoot canalsBracesBleeding GumsExtractionsPostsSensitive teethBridgeworkImplantsBad BitePartial or full denturesVeneersTemporariesPorcelain crowns or inlaysDeGussa Porcelain crowns or inlaysGold crowns or inlays
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?

restfulrestlesshard to sleepwake up oftenget up during the nightbad dreams
Any complaints?
What time do you usually go to sleep?
Number of hours of sleep per night?
2. Digestion
How is your digestion?

pooracid refluxburp oftenbloatingburning or pain in stomach
Any complaints?
3. Urination
How are your daily urinations?

Every 2 to 3 hoursToo frequentSense of urgencyToo little amountToo large amountBurningDribblingUp at night several times
Any complaints?
4. Bowels
How are your bowel eliminations? How Often?

Once per day2 times daily3 times dailySkip daysAmount: normalAmount: too littleAmount: too largeConsistency: normalLots of mucusToo hardVery softDiarrheaLots of gasFoul smellColor: brownColor: blackColor: whitish
6. Exercise
What kind of exercise do you do?
How often?
5. Women Only
Are you pregnant?

YesNo
Are you breast-feeding?

YesNo
Do you have monthly periods?

YesNo
Date of last menstrual period?

MonthDayYear
Are you going through menopause?

YesNo
Have your periods stopped?

YesNo
Have you had a hysterectomy?

YesNo
(If so, when?)

MonthDayYear
Menstrual Cycle
Are your monthly periods regular (28 day cycles)?

YesNo
Number of days of your menstrual flow?
Do you experience any of the following symptoms associated with your period?

crampingbloatingfeeling weakmood swingscravingsheavy bleedingback painheadachesbright red blooddark clotty blood.
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.
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First Time Evaluation