NEW PATIENT FORMS

 

 

 

Name: _____________________________

 

Age: ______________________________

 

Blood Pressure: ___________

 

Please select if illness is chronic or acute:

 

Chronic: ________

 

Acute: _________

Describe Symptoms:  chronic neck, back pain and stomach pains

 

Current Physical Condition:

 

Good: _________ Fair: _______Weak:___________

 

 

Nutrition: (Please describe diet)

 

____________________________________________

 

Occupational Hazards: (Description of work environment)

 

_________________________________________________

 

Describe work schedule and rest patterns:

 

_________________________________________________

 

 

 

Stress Factors:

 

__________________________________________________

 

Environmental Factors: (Home)

 

___________________________________________________

 

Previous Chronic Illnesses:

 

Health: ________________Emotional:_________________Mental:__________________

 

Injuries: __________________________________________________________________

 

 

List body parts where discomfort is present: (external and internal)

 

 

Describe metabolism: (obesity, swelling, hypoglycemia)

 

_________________________________________________

 

List bone and joint disorders:

 

__________________

 

__________________

 

__________________

 

List of Allergies:

 

 

 

Bowel Movement Patterns:

 

____________________________________________________

 

 

 

Patient Signature: _____________________ Date of Consultation:_____________________

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SHIZEN NATUROPATHY (SHINE)

 

Patient's Name (Last, First, MI): ____________________________________________________________ Patient's Home Phone Number: _____________________ Alternate Phone Number (o cell or o work): __________________________ E-Mail Address: Address: __________________________________________________________ Apt. # ____________ City: ________________________________ State: _________________ Zip: ________________ Date of Birth: ____________________ Age: ______ Sex: M F Social Security Number: ___________________________ Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Widowed Patient’s Employer: ____________________________ Employment Status: [ ] Full time [ ] Part time [ ] Unemployed [ ] Retired [ ] Student [ ] Other: __________________ INSURANCE INFORMATION Primary Insurance: ____________________ Patient is Subscriber/Policy Holder: Y N Secondary Insurance: ____________________ Patient is Subscriber/Policy Holder: Y N INSURED INFORMATION (IF OTHER THAN PATIENT) - We will request to scan your ID and insurance card Subscriber/ Policy Holder: _________________________________________ Relationship to Patient: ________________________ Address: _____________________________________________________________________________________________________ Social Security Number: _________________________________ Date of Birth: __________________________________________ His or Her Employer: ____________________________________ Work Phone Number: _________________________________ RELEASE OF INFORMATION I hereby give permission to the person(s) listed below to receive information about the care of the above named patient. Name(s): ______________________________________________ Relationship to Patient: __________________________________ Nature Well NY reserves the right to charge a fee for any scheduled visits that are: Cancelled with less than 24 hours notice 2. Are missed without calling to cancel ( no show) Cancellation Fee schedule: New Patient $50.00; Established Patient: $35.00 Patient / Parent or Guardian Signature: __________________________________________________ Date: ____________________ ___________________________________________ ® Emergency Contact: ___________________________________________ Relationship to Patient: ____________________________ Address: _____________________________________________________ Phone number: ________________________ Revised 08/22/16  Nature Well NY HEALTH HISTORY Personal Information Date:_______________ Patient Name: __________________________________ Birth Date: _____/_____/_____ Age: ____ Occupation __________________ Marital Status: ______ Name of Partner/Spouse: _______________ Race: [ ] Asian [ ] Black or African American [ ] Native American [ ] White / Caucasian [ ] Other: ___________ Ethnicity: Do you identify with an Ethnic origin? If yes, please note: ______________________ Number of children: ______ Children’s Names/Ages: _______________________________________ Names/Specialties/Locations of Other Physicians Caring for You, including previous primary care doctor:_______________________________________________________________________________ _____________________________________________________________________________________ ___________________________________________________________________________________ Medical Information Please list any MEDICATIONS you are currently taking, prescribed or over the counter (use the back of the page if needed and indicate so): Any Allergies to Medication or Food (list reactions): _________________________________________ Preferred Pharmacy: __________________________________________________________________ Date of Last Complete Physical Exam: ____________ Date of Last Blood Work: ___________________ Date of Last Colonoscopy: ______________ Date of Last Tetanus Shot: _________________________ For Females: Date of Last Menstrual Period: _________ Date of Last Pap Smear: _________________ History of Abnormal Pap (list date/s)? ___________ Date of Last: Mammogram: _____ DEXA: ______ Number of Pregnancies: ________ Miscarriages: ______ Terminations: _______ Living Children: _____ Method/s of Contraception: ______________________________________________________________ Medication Dosage Route Frequency Revised 08/22/16 If YOU or a FAMILY MEMBER has had any of the following, please circle and indicate which family member when applicable: ADD/ADHD Anemia Allergies/Hay Fever Asthma Arthritis Anxiety/Depression Alcoholism Blood Clots Cancer, Type/s _________________________ Type 1 or 2 Diabetes Fractures Gynecological Disease High Blood Pressure High Cholesterol Heart Attack Kidney Disease Liver Disease Neurological Disease Osteopenia/Osteoporosis Respiratory Disease Skin Disease Stomach/Colon Disease Stroke Seizure Disorder Thyroid Disorder Sexually Transmitted Other: _______________________ Please list any SURGERIES you have had and include the month/year: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _________________________________________________________________________________ Social Information Tobacco Use: Do you smoke? _____ If so, how many cigarettes/cigars per day: _____ No. of years smoking: _____ Do you chew tobacco? _____ Have you thought about quitting? _____ Have you quit before? ____ How long?____ Alcohol Use: Do you drink alcohol? ____ If so, what type? ____________ How many in 1 week? _____ Drug Use: Any history of illegal drug use? _____ If so, what type/s? __________ When? ____________ Do you exercise? _____ What activities do you do, and how often in 1 week?_____________________ ____________________________________________________________________________________ Are you on any special diet? _____ If so, what? _____________________________________________ Do you consume any caffeinated products? _____ If so, what and how much per day? ______________ Have you recently noticed an increase in sadness or gloominess? _____ Have you lost interest in enjoyable activities? _____ Do you have a living will? _____ If yes, please provide us a copy. _______________________

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