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1、Integrative Medicine & Acupuncture, P.C.PATIENT REGISTRATION FORMNAME:DATE OF BIRTH:ADDRESS:TOWNZIPHOME PHONE:CELL/WORK PHONE:EMAIL ADDRESS:NAME OF PRIMARY PHYSICIAN:NAME OF SPECIALISTS:Sign up for Dr. Karens mailing list (free online classes)? YES/NOIN CASE OF EMERGENCY, CONTACT:Name:Relation:Home
2、Phone:Work Phone:HEALTH & FAMILY HISTORY1. Do you or any of your family members have/had the following health problems?Health Problem:You - when diagnosed?Family Member - who?AlcoholismAllergies (environmental)ArthritisCancer (what type?)DiabetesDigestive ProblemsDrug AddictionEye Disease (e.g.G)auc
3、oina)Heart DiseaseHead Injury/FallsHigh Blood PressureHigh CholesterolLung Disease/AsthniaMental Health ProblemsMigrainc/hcadachcsSinus InfectionsSkin ProblemsStrokeThyroid DiseaseOther2. Is anyone in your immediate family deceased? If yes, please state cause of death:3. Please list any MEDICATION A
4、LLERGIES and the type of reaction you had:4. Please list any ER visits, hospitalizations/surgeries and the approximae dates:Reason for ER Visit/Hospitaiizations/Surgeries:Dates:5. Please list any medications you are currently taking, including over the countersupplements, herbs and vitamins (use sep
5、arate sheet of paper if needed):Name:Dosage & Frequency:SOCIAL HISTORY6. Check which substances you use and describe how much you use them: AlcoholCaffeineTobaccoQuit Date:7. Marital Status:8. Occupation:9. Spiritual Beliefs:10. Number of Children, if any:STRESS & SAFETY ASSESSMENT11. Do you eat foo
6、ds with artificial sweeteners (aspartame, Splenda)? YNDo you eat foods with MSG (potato chips, canned so up etc.)? Y N12. On a scale of 1 -10, rate your current stress levels:13. What types of mobile phones do you have in your home?14. Do you have a cordless phone in your home? Y NIf you have a cord
7、less phone, where is the base located?15. Circle what you have in your bedroom: clock radio, cell phone or cordless phoneDo you keep a television or computer in your bedroom? Y N16. If you have Wi-Fi (wireless internet) at home, where is the router located?17. If youve had a significant fall or head
8、 injury, when was it?18. Do you consistently wear your seatbelt? Y NGeneral:Brain/Ncrvous SystemDigestive System Fatigue Headaches Constipation/hard Sleep Difficulty Dizzinessstoolso Awakenings o Falling asleep Brain fog Memory Loss Diarrhea/unformcd stoolso Lack of dreaming Anxiety Pale stool color
9、o Wake up tired Depression Blood in stool Appetite Issues Mood swings/Irritability Abdominal bloating Feeling Stress Nerve pain Abdominal pain Weight Gain Weight Loss Tingling or NumbnessReproductive Organs Undigested food in stool HeartburnEye, Ear, Nose, ThroatWomen: Indigestion Eye symptoms Stuff
10、y or runny nose Vaginal itching or discharge Menstrual cramps Excessive gas Seasonal allergies Irregular periodsSkin/Hair/Nails Sore Throat Heavy periods +/- clots Rashes Hearing issues PMS Hot Flashes Acnc WrinklesLung Vaginal dryness Premature gray hair Wheezing Painful sex Hair Loss Shortness of
11、breath Low libido Brittle Nails Coughing Infertility age spots Mucus productionHeart Inability to lose weight Breast lumps or tenderness Men: Moles/Warts Dry skin Chest discomfort Low libidoImmune System Palpitations/skipped beats Hair loss Environmental alleif Heart rhythm problems Inability to los
12、e weight Food sensitivities Frequent colds/flusMuscles/JointsUrinary System Swelling in legs Joint swelling Excessive urination Excessive immune Joint pain Dark urinereaction (or Muscle spasms Narrow streamautoimmune) Muscle knots/trigger points Tightness/inflexibility Spine issues Prostate issues (
13、men) Painful urinationOTHER:The purpose of this questionnaire is to assess your goals and expectations for your treatment and care. Based on what you answer, we will be more able to tailor our approach to your specific needs. Choose the answer that best represents how you feel. Your honesty is great
14、ly apprecia/ed.Regarding your treatments, what statement best represents your interest: Fm mainly here for symptoms relief and am not interested in much else. Id like symptom relief but also teaching on how to prevent further deterioration of my condition or how I can treat myself at home. Id like symptom relief, but am also interested in learning a holistic approach to reversing the aging/illness process.How willing are you to make lifestyle changes to heal or reverse your illness? Mostly unwilling. I just want you to fix me. Somewhat wi
