New Patient Health Information Thecontact informotion you provide us will be held in confidence and will only be usedfor documentation in your healthcare file and for contacting you regarding issuesrelated to your care at Hearthstone Integrated Natural Health. Name: Age _ Date of Birth _ Gender(circle) : Male Female Mailing Address: City: _ State: _ Zip Code Home Phone # _ E-Mail (if applicable) Cell Phone # _ Work Phone #(ifapplicable) _ Name of Parent/Guardian (i/opplicoble) _ Employer Occupation _ Spouse/Partner (if applicable): Phone: _ Emergency Contact: Phone: _ How were you referred to our office? (please circle) Website Newspaper article Advertisement Friend _ Another healthcare practitioner Other _ In general, please describe what concerns bring you into our office today: How long ago (approximately) did these issues begin? _ Is your condition job-related or due to an accident? _ Date/location of accident or incident _ Are you experiencing any pain or other symptoms today? Do you suffer from another condition for which you are NOT consulting with us? _
Transcript
New Patient Health Information
The contact informotion you provide us will be held in confidence and will only be usedfor documentation in your healthcarefile and for contacting you regarding issuesrelated to your care at Hearthstone Integrated Natural Health.
Name: Age _
Date of Birth _ Gender(circle) : Male Female
Mailing Address: City: _
State: _ Zip Code Home Phone # _
E-Mail (if applicable) Cell Phone # _
Work Phone #(ifapplicable) _
Name of Parent/Guardian (i/opplicoble) _
Employer Occupation _
Spouse/Partner (if applicable): Phone: _
Emergency Contact: Phone: _
How were you referred to our office? (please circle)
Website Newspaper article Advertisement Friend _
Another healthcare practitioner Other _
In general, please describe what concerns bring you into our office today:
How long ago (approximately) did these issues begin? _
Is your condition job-related or due to an accident? _
Date/location of accident or incident _
Are you experiencing any pain or other symptoms today?
Do you suffer from another condition for which you are NOT consulting with us? _
PAIN RATING CHART
NAME: - ----DATE:----
INSTJlUCl'IONS: For each.question below, please choose the number whichbest desen1»es your pain.
1. What is the level o~your pain RIGHT NOW?
'0 0 .. 0 0 01 2 345
NO PAIN
000006 7 8 9 10
UNBBARABLJlPAIN
2. What is the level.afyour TYPICAL of AvERAGE pain?I .
o 01 2
NO PAIN
o 0 -0 ~O345 6
o 07 8o 09 10
UNB&BABLBPAIN
3- What is the level afyour pain at ibtWOBSTI
000 0 0 0 0 01 2 3 ·4 5 6 7 8
NOPAIN' .
Please mark-on the I
pictwes whei-cYOU.~ ha'ring COlDPIaints.
".••..
o 09 10
~LEPAIN
Do you have any allergies or food sensitivities that you are aware of? Please describe:
Have you ever suffered a fracture or concussion, or head injury of any kind? Please describe:
Please circle any surgical procedures you have experienced:
DATE PROCEDURE DATE PROCEDURE DATE OTHER (Please list)
Tonsillectomy Thyroid
Gall bladder Stomach
Back Surgery Knee
Dental Surgery Shoulder
Female Organs Foot
Appendectomy Rectal
Hernia Sinus
Please circle or write in symptoms that you are experiencing currently or in recent history:
Energy and Mood Gastro-Intestinal Eye/Ear /Nose/Throat RespiratoryFatigue Abdominal pain Asthma Chest painAnxiety or Gas/bloating Earache Difficulty breathingdepressionPoor concentration Constipation Hearing problems Chronic coughSudden weight loss Diarrhea Cold/hayfever / congestionor weight gainMood swings Poor digestion Sinus problemsSleep disturbances
OTHER: OTHER: OTHER: OTHER:
Genito-Urinary Musculo-skeletal Cardio-Vascular Skin/AllergiesBed wetting Back pain High blood pressure Sensitive skin/skin
eruptionsFrequent or painful Foot/knee/shoulder Chest pain Psoriasisurination or wrist painBlood in urine/stool Tremors/twitching Strokes EczemaProstate pain Joint inflammation Varicose veins Bruise easily
OTHER: Headaches/Migraines OTHER: OTHER:
OTHER:
NO If so, when were your most recent vaccinations
Please list any prescription medications you are currently taking:
Please list any nutritional supplements (vitamins, minerals) you are currently taking:
Do you regularly experience food cravings? (Le. for sweets, caffeine, salty foods, meat etc.) Please describehere: _
Have you ever been vaccinated? (please circle) YES(including flu vaccination)? _
Have you ever taken antibiotics? (please circle) YES NO If so, when did you most recently take one?
Do you currently have, or have you ever had, mercury-amalgam fillings in your teeth? YES NO
Have you or your family suffered any major losses or life changes recently? _
Please share anything else you believe is relevant to your health concerns here:
Are you consulting any other healthcare practitioners for the concerns that brought you into our office today?
YES NO
If so, may we consult with him/her in order to better coordinate your care? YES NO
Practitioner's Name and Telephone #
The information on this document is true to the best of my knowledge.
Signature of Patient or Parent/Guardian (if applicable) Date
