Please allow 30 minutes to complete this detailed new patient form. Please fill out as thoroughly as possible and do not leave any fields blank. The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.

Adult New Patient

Name

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Primary Phone

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Secondary Phone

*

Date of Birth

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Street Address

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City

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State

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Referred By

Gender

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Employment Status

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Occupation

*

Employer Name

Marital Status

Number of Children

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Emergency Contact Person

*

Emergency Contact Phone

*

Medical History

Hospitalizations

Give the following information for the last three times you have been hospitalized starting with the most recent (except normal pregnancies).

Include type of illness, month and year hospitalized, name of hospital, city and state.

Allergies

Current Medications

Currently used medicinal herbs, vitamins, teas

Do you use:

Coffee

If yes, amount of coffee per day/week/month:

Do you use:

Cigarettes

If yes, amount of cigarettes per day/week/month:

Do you use:

Alcohol

If yes, amount of alcohol per day/week/month:

Do you use:

Other drugs

If yes, amount of other drugs per day/week/month:

Year	Tests	Year	Immunizations
	Chest X-Ray		Smallpox
	Electrocardiogram		Tetanus
	TB Test		Polio
	GI series		Typhoid
	Kidney X-Ray		Mumps, Measles
	Barium Enema		Flu
	Other X-Rays (please list):		Other (please list):

Personality and Preferences

Describe an ideal day in terms of weather and temperature

What are you most sensitive to? (eg. noise, odors, light, pain)

What are your fears?

Do you have any hobbies?

(Women only) What symptoms do you experience premenstrually?

Describe any recurrent dreams, important dreams in your life or recurrent themes in your dreams

How is your energy? Is there any particular time of day when it is lower or higher?

What environment do you feel most comfort in? (IE desert, mountains, ocean, city)

How is your sexual interest/drive?

What do you most like to eat or crave?

What is your favorite color?

What foods do you most dislike?

How is your thirst?

What temperature do you like fluids?

Are there any foods that you are sensitive to or allergic to?

Family History

Click the check box in the appropriate columns for any illnesses that you or your relatives have had:

Illness	Self	Dad	Mom	Siblings	Kids	Grand parents
Allergies
Anemia
Arthritis/ Gout
Bleeding Problems
Cancer
Epilepsy
Diabetes
Alcohol/ Drugs
Eczema
Emphysema
Heart Trouble
Hepatitis
High Blood Pressure
Frequent Infections
Kidney Problems
Mental Illness
Migraines
Abnormal Periods
Psoriasis
Pneumonia
Polio
Prostate Problems
Rheumatic Fever
Stomach Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Weight Problems

Thank you

Questions, Comments, or Additional Information

The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.