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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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Employment Information
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Patient Employer
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Occupation
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Employer Address
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City
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State
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Zip
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Work Phone no / Ext
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Relationship
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In case of emergency
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Phone
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Name
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Family Physician
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Patient Spouse
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Phone
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Phone
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History of Swelling Feet?
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Who may we thank for referring you to us?
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General Health
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Present Status
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Are you in good health at the present time
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Are you under a doctor's care at the present tim
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Are you taking any medication at the present tim
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History of Constipation (difficulty in bowel mov
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History of frequent Headaches?
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Migraines?
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Do you smoke?
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History of Heart Attack or Chest Pain?
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History of Swelling Feet?
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Any Allergies to any medications?
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History of Diabetes?
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Do you suffer from Allergies
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History of Glaucoma?
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History of High Blood Pressure?
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History of Sleep Apnea
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Serious Injuries
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Any Surgery? (non-orthopedic)
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Past Medical History
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Past Medical History (Check all that apply)
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Comments
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Reproductive Health
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Menopause
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Average Cycle Duration (in days)
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Are you regular?
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Pain Associated?
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Last Menstrual Period
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Birth Control?
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Last Annual Exam?
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Check all that apply
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Male History
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Sexual Function (Check all that apply)
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Past Medical History (check all that apply)
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Comments
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Family Medical History (check all that apply)
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Nutritional health
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Nutritional Assessment
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Do you wake up hungry during the night?
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How often do you eat out?
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How often do you eat "Fast Foods"?
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Do you wake up hungry in the morning?
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What time of the day are you mostly hungry?
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What is your activity level
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Inactive
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Light Activity
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Moderate Activity
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Heavy Activity
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Vigorous Activity
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On average how many hours of sleep you get at ni
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Allergies
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Allergie Assessment (check all that apply)
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The symptoms most commonly associated with aller
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Heavy Metal Toxicity
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Heave Metal Toxicity Symptoms
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Have you had sore gums (gingivitis) often
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Have you had mental symptoms such as confusion
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Have you had ringing in the ears (tinnitus)?
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Have you had unusual shakiness (tremors)
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Do you have "brown spots" or "age spots"
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Have you tended to have more cold , flu
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Have you had food allergies or intolerance's
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Have you been to many doctors for your health
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Do you have numbness or burning sensation
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Do you have numbness or unexplained tingling
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Do you have 10 or more "Silver" fillings?
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Do you often have a metallic taste in your mouth
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Have you ever worked as a painter or in manufact
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Have you worked as a dentist, hygienist
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