New Patient Profile

Health Information (Confidential)
Below, please list three to five of your most important health concerns, in the order of importance to you. (For example, #1 is most important and #5 is least important). You are welcome to enter as much information as you feel is necessary.
Present Health Concerns.
What is Your Main Complaint/Problem?
What Makes it Better?
What Makes it Worse?
What Kinds of Tests or Exams Have You Had for it?
What is the Diagnosis?
What Kind of Medications/ Supplements Have You Taken for it?
Please Elaborate if Necessary

Medical Summary
Please write a chronological history that summarizes your medical history in regards to the above concerns. Example: I was well until January 2002 when I had the flue. Since then, I have had daily headaches, etc. Please feel free to elaborate
Summary
1.
2.
3.
4.
5.
Your Questions: What questions do you have for today's visit?
Allergies
Please list all food, environmental and/or drug allergies
List Allergies
Current Medications
Have you taken thyroid medication in the past if so what kind, dose and frequency? Have you taken bio-identical hormone replacement in the past and if so what form and at what frequency? Please list the medications and/or supplements that you are currently taking, with dosages, including prescription medications (e.g. Prozac, atenolol, etc.), non prescription medications (e.g., asprin, Tylenol, ibuprofen) and/or health supplements (e.g., vitamins, minerals, herbs). Please indicate name of medication, dose in milligrams or grams (or number of capsules, tablets), Frequency taken and Duration you've been taking it.
Medications (one per line)

Medical History
Please list all previous medical procedures, surgeries, hospitalizations & serious illnesses. Indicate the approximate date/year and the Surgery, hospitalization, procedures, serious illnesses and/or injuries
History (One per line)
Diet: Do you follow any particular diet regimens or restrictions?
Exercise: Do you exercise regularly?
- Yes
- No
If YES - what do you do? If NO - what keeps you from exercising?
Habits and Lifestyle: Which of the following do you use?
- Tobacco/cigarettes
- Cola/Soda
- Recreational Drugs
- Alcohol
- Black Tea
- Prescription Drugs
Email
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Contact Information