Patient Name Date of Birth How Long? Reason for Visit Severity? (1-10) #1 #2 #3 Insurance Information Company ID number Group Number Plan Name Is patient same as insured? Do you have a secondary? Are these complaints associated with... An Auto Accident? Company Work Injury? Claim Number Employer Accident Date & Location Date Personal Information Male Female Phone Email Address City, St. Emergency Contact Phone Privacy Information: I agree to the privacy practices of this office. Initial:________ Medical Information (check all that apply) Allergies Skin Conditions Asthma Fatigue Diarrhea Constipation Heartburn Insomnia Pregnant Surgeries Fractures High Cholesterol Diabetes Hypertension Cancer Nausea Vomiting Blurring of Vision Kidney Disease Heart Disease Menopause Menstrual Issues PMS Headaches Anemia Chronic Pain Arthritis Weight Concerns Patient Name Medications Name Dosage #1 #2 #3 Reason #4 #5 Are there more? Supplements, Herbs, Vitamins, etc. (please list) Dietary Information (please try to list everything you ate or drank yesterday) Breakfast Lunch Dinner Other Sleep Information About how many hours of sleep do you get per night? Cautions and Concerns Is there any chance you are pregnant? Do you have any electronic implants? Do you have AIDS, Hepatitis, Diabetes, Lymphedema, or Cellulitis? Anything else we should know? Patient Name Medical History (Please list any major surgeries including tonsils, gall bladder or appendix, illnesses, or important medical events and the dates.) Family Medical History (indicate any relations who suffered from cancers, heart disease, strokes, auto-immune conditions or other significant illnesses.) Current and Recent Medical Care Who is your current primary care provider? Practice Location? Are you seeing any specialists? (please list) Release Disclosure In the interest of providing for the best possible coordination of care our office sends a letter to patients’ primary care providers, informing them of our findings, treatment modalities and goals of treatment. This also opens lines of communication ensuring that all concerns are addressed. Do you give us permission to send your primary care physician a report of our findings and treatment intentions? Signature: Any other providers you would like us to contact? Date: Patient Name Multiple Symptom Questionnaire Rate each of the following symptoms over the past 60 days. Rating 0- Never or almost never have the symptom Scale 1- Occasionally have it, but not severe 2- Occasionally have it, and it is severe 3- Frequently have it, but it is not severe. 4- Frequently have it, and it is severe. Head Headaches Skin Acne Faintness Dizziness Insomnia Total for Section Hives Hair Loss Flushing Excessive Sweating Eyes Watery or Itchy eyes Swollen, red or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (does not include far-sightedness) Total for Section Nose Stuffy nose Sinus Problems Hay Fever Sneezing Attacks Excessive Mucus Production Total for Section Total for Section Heart Irregular or skipped beats Rapid or Pounding Heartbeat Chest Pain Total for Section Lungs Chest Congestion Asthma, bronchitis Shortness of Breath Difficulty Breathing Total for Section Mouth and Throat Chronic coughing Gagging, frequent need to clear throat Sore, hoarse throat, loss of voice Discoloration or swelling of gums, lips, tongue Canker Sores Digestive Tract Nausea, Vomiting Diarrhea Constipation Bloated Feeling Belching, Passing gas Heartburn, Reflux Intestinal, Stomach Pain Total for Section Total for Section Patient Name Multiple Symptom Questionnaire Pg 2 Rate each of the following symptoms over the past 60 days. Rating 0- Never or almost never have the symptom Scale 1- Occasionally have it, but not severe 2- Occasionally have it, and it is severe 3- Frequently have it, but it is not severe. 4- Frequently have it, and it is severe. Joint/Muscles Pain or aches in joints Mental Poor memory Arthritis Stiffness or limited movement Pain or Aches in Muscles Feeling of weakness or tiredness Confusion, Poor Comprehension Poor Concentration Poor Physical Coordination Total for Section Weight Binge eating/drinking Craving certain foods Excessive Weight Compulsive Eating Water Retention Underweight Difficulty Making Decisions Stuttering or Stammering Speech Slurred Speech Learning Disabilities Total for Section Emotions Mood Swings Anxiety/fear/nervousness Anger/irritability Total for Section Panic Attacks Depression Energy/Activity Fatigue, tired, sluggish Apathy, lethargy Hyperactivity Restlessness Total for Section Total for Section Total for All Sections Other Frequent Illness Frequent or Urgent Urination Genital Itch or Discharge Total for Section Date