WON INSTITUTE OF GRADUATE STUDIES

New Patient Information Form Date__________________________________________________ Name_________________________________________________ Home Phone__________________________________________________ Address_______________________________________________ Cell Phone____________________________________________________ City__________________________ State______ Zip___________ Work Phone__________________________________________________ Occupation____________________________________________ Email________________________________________________________ DOB_________________________ Age_______ Height________ Weight_________________ Sex:

Female

Marital Status :

Single

Married

Domestic Partner

Divorced

Widowed

Separated

Male

Transgender

How did you learn about our clinic?_____________________________________________________________________________________ In case of emergency notify______________________________________________________ Relationship___________________________ Their home phone________________________ Work phone___________________________ Cell phone____________________________ Physician______________________________________________ Physician’s phone______________________________________________ Physician Address____________________________________________________________________________________________________

Street

City

State

Zip code

The reason for your visit?______________________________________________________________________________________________ ____________________________________________________________________________________________________________________ How long have you had this condition?____________________ Have you had it in the past?_____________________________________ _____________________________ If yes, (in the past) describe when_______________________________________________________________________________________ What makes it better?_________________________________________________________________________________________________ What makes is worse?________________________________________________________________________________________________ Is your condition... : getting worse__________ getting better____________ constant______________ comes and goes______________ If

applicable, circle a number to indicate your level of pain.

Minimal = 1 2 3 4 5 6 7 8 9 10 = extreme

If you have been given a diagnosis, what is it?___________________________________________________________________________ Diagnosing physician___________________________________

Are any other doctors treating this condition? Y / N

Are you under the care of another physician for any other problems? (list problem and physician)_______________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ What kinds of treatments have you tried?________________________________________________________________________________

List all medications, hormones, laxatives, herbs, homeopathics, and supplements you are taking and for what reason: ____________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________

Medical History Date of your last physical exam_____________________________________ By whom?_________________________________________ List surgeries and dates_______________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Significant accidents and traumas with dates____________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Do you: Smoke How much and how often:___________________________________________________________________________________ Drink alcohol How much and how often:_____________________________________________________________________________ Take recreational drugs How much and how often:____________________________________________________________________ Do you have or have ever had: AIDS, or HIV

Arthritis

Tuberculosis

Dyslexia

Heart trouble

Cancer

Sexually transmitted disease

Kidney or bladder trouble

Hepatitis

Epilepsy

Thyroid problems

Scarlet fever

Gallstones

Hemophilia

Ulcers

Sudden weight loss

Rheumatic fever Have you ever taken adrenal corticosteroids (cortisone, prednisone, etc)? How long? ________________________________________ Have you had more than 2 courses of antibiotics in your lifetime?

Y/N

How many?______________________________________

Do you have silver amalgam fillings? ___________________________________________________________________________________ Unusual birth history (prolonged labor, forceps delivery, C-section, etc)? ____________________________________________________ Please list scars from accident/surgery:_________________________________________________________________________________ What inoculations have you had? Tetanus (lockjaw)

Smallpox

Diphtheria

Poliomyelitis

Pertussis (whooping cough)

Rubella (German measles)

Measles

Flu



Other______________________

What inoculations have you had in the last year? _________________________________________________________________________ Where have you traveled outside this country? ___________________________________________________________________________ Family Medical History Has anyone in your family had any of the following disorders? Alcoholism

Asthma

Diabetes

High blood pressure

Lung disease

Allergies

Cancer

Epilepsy

Kidney disease

Mental Disorder

Arthritis

Coronary artery disease

Heart disease

Liver disease

Stroke

Symtoms (Do you suffer from any of the symtoms below) General Head or chest cold

Night sweats

Anemia

Recent weight loss

Flu

Perspire easily w/o exertion

Always fatigued

Recent weight gain

Recurrent fever

Rarely perspire

Fatigued easily

Often thirsty

Sudden drop in energy

Chills

Jaundice

Seldom thirsty Head, Ears, Nose, Mouth and Throat Frequent colds

Dizziness or loss of balance

Deafness

Sores on tongue

Sinus congestion or pain

Concussion

Nasal congestion

Sores in mouth (canker)

Facial pain

Seizures

Runny nose

Sores on lips (fever blister)

Jaw tension or clicking (TMJ)

Headache

Nose bleeds

Difficulty swallowing

Grinding teeth

Migraine Headache

Sneezing

Lump or pit in throat

Frequent dental cavities

Congestion in ears

Allergies

Sore throat

Gum problems

Earache

Decreased sense of smell

Strep throat

Bleeding gums

Ringing in ears

Dry mouth

Swollen lymph nodes

Dentures

Difficulty hearing

Excessive saliva or drooling

Tonsillitis

Nearsighted (myopia)

Night blindness

Eye pain

Conjunctivitis

Farsighted (hyperopia)

Sensitivity to light

Dry eyes

Use eyeglasses or contacts

Astigmatism

Blurred vision

Watery eyes

Blindness

Glaucoma

Floating Spots

Itchy eyes

Cataracts

Pressure behind eyes

Red eyes

Chronic cough

Thin, watery phlegm

Pneumonia

Asthma: more difficult exhale

Dry cough

Clear or white phlegm

Pain with deep breath

Asthma: more difficult inhale

Tight , rattling cough

Yellowish phlegm

Shortness of breath

Asthma: worse on exhale

Loose cough

Blood in phlegm

Emphysema

Thick, sticky phlegm

Bronchitis

Wheezing

Eyes

Respiratory

Cardiovascular High blood pressure

Angina or chest pain

Varicose veins

Cold hands

Low blood pressure

Coronary heart disease

Bruise easily

Cold feet

Blackouts or fainting

High cholesterol

Anemia

Hot hands or palms

Irregular heartbeat

Stroke

Edema

Hot feet or soles

Heart valve problem/murmur

Blood clot

Swelling of hands

Generally too hot

Rapid heartbeat/palpitations

Phlebitis

Swelling of feet

Generally too cold

Gastrointestinal Constipation

Undigested food in stool

Blood in stool

Hiatal hernia

Hard stools

Black stool

Lower abdominal pain/ cramping

Vomiting

Hemorrhoids

Belching

Upper abdominal pain/cramping

Colitis

Frequent laxative use

Stomach acidity

Ulcer

Diarrhea

Diverticulitis

Indigestion

Nausea

Loose stools

Parasites

Gurgling noise in stomach

Erratic bowel movements

Mucous in stool

Abdominal bloating

Bad breath

Poor appetite

Gas (flatulence)

Foul smelling stools

Excessive appetite

Bowel movements feel incomplete

How often do you have a bowel movement?______________________________________________________________________________ Urinary and Genital Scanty or small amount of urine

Decreased flow of urine

Sores on genitals

Dark urine

Flow does not stop quickly

Pain during intercourse

Strong smelling urine

Dribbling

Excessive sexual energy

Low sexual energy

Cloudy urine

Bed wetting

Profuse or large amount of urine

Inability to achieve orgasm

Low sperm count

Clear urine

Pain or burning when urinating

Pain in bladder area

Prostate problems

Unable to hold urine

Blood in urine

Urgency to urinate

Bladder infection

Premature ejaculation

Ejaculation during sleep

Frequent urination

Kidney infection

Difficulty urinating

Kidney stones

Inability to maintain erection



How often do you urinate in 24 hours?_______________________ How often do you wake to urinate at night?_____________________ Pregnancy and Gynecology Number of pregnancies_________________

Clots

Vaginal discharge:strong odor

Number of births_______________________

Dark purple

Vaginal discharge brownish

Premature births________________________

Dark brown

Vaginal discharge:white/curd-like

Miscarriages___________________________

Red

Vaginal discharge:frothy & profuse

Abortions______________________________

Light colored/pale blood

Vaginal discharge:itchy

Difficult deliveries

Painful periods

Vaginal discharge:burning

Caesarean sections

Endometriosis

Abnormal pap

Age of children

Cramping before period starts

Uterine fibroids

Age at first menses

Cramping after period starts

Ovarian cysts

Date of last menses:__/__/___

Low backache with period

Breast cysts or lumps

Duration of flow

Spotting between periods

Pelvic inflammatory disease

Pregnancy and Gynecology (Continued) Length of cycle

Missed periods

Currently have an IUD

Age at start of menopause

Premenstrual irritability

Previously had an IUD

Age menses stopped

Premenstrual emotional sensitivity

Hysterectomy

Premenstrual breast tenderness

Reason for______________________



Current use of birth control pills Previous use of birth control pill

Premenstrual bloating

Other birth control__________

Premenstrual fluid retention

Cannot maintain pregnancy

Premenstrual headache

Trying to become pregnant

Have not yet begun menstruating

Premenstrual constipation

Infertility

Irregular cycle

Premenstrual diarrhea

Pregnant

Heavy flow

Hot flashes

Nursing

Light flow

Vaginal discharge: no odor

Nausea or morning sickness

Oophorectomy Reason for______________________

Any other pregnancy or gynecological problems?_____________________________________ Date of last pap test________________ Musculoskeletal Neck pain/stiffness

Mid back pain/stiffness

Leg or calf cramping

Shoulderblade pain

Low back pain/stiffness

Ankle pain/stiffness

Shoulder joint pain/stiffness

Sacroiliac pain/stiffness

Weak ankles

Upper arm pain/stiffness

Hip joint pain/stiffness

Foot or toe pain/stiffness

Elbow pain/stiffness

Pain into thigh or upper leg

Numbness or tingling in feet

Wrist pain/stiffness

Pain into calf or lower leg

Muscle spasms

Hand or finger pain/stiffness

Weak legs

Muscle weakness

Numbness or tingling in hands

Knee pain/stiffness

Paralysis

Upper back pain/stiffness

Weak knees

Stiff all over

Is the problem helped by:

______ pressure

______heat

______cold

______other_______________________________

Is the problem aggravated by: ______ pressure

______heat

______cold

______other_______________________________

Skin and Hair Rashes

Herpes Zoster (shingles)

Recent change in mole

Fungus on skin

Hives

Boils

Warts

Fungus under nails

Itching

Pimples or acne

Dry Skin

Weak or brittle nails

Eczema

Ulcerations or sores

Moist feet

Loss of hair

Psoriasis

Recent moles

Moist palms

Dandruff

Any numb areas?

Yes

No Where?__________________________________________________________________________________

Sleep Difficulty falling asleep, wired

Nightmares

Needs to take naps

Shallow sleep

Snoring

Sleep too much

Dream disturbed sleep

Difficulty waking in a.m.

Sleep too little

Wake at night–thinking

Wake up unrefreshed

Sleep on a waterbed

Wake at night-mind empty, eyes open

Sleepy in afternoon

Sleep with an electric blanket

How many hours do you sleep in a 24 hour period?________________________________________________________________________

Emotional Depression

Mood swings

Frequent crying

Suicidal feelings

Manic episodes

Anxiety or fear

Frequent anger or irritation

Obsessiveness or compulsiveness

Indecisiveness

Sadness or grief

Difficulty handling stress

Tendency to repress emotions

Have you ever been emotionally, physically or sexually abused? ____________________________________________________________ Have you ever been treated for emotional problems? ______________________________________________________________________ Have you had any recent stressful experiences (divorce, death of a loved one, bankruptcy, loss of a job, illness, injury, etc.)? _____________________________________________________________________________________________________________________ Is there a constant stress in your life, at work, with your family, etc.?_________________________________________________________ Any other emotional problems?__________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________

The information on pages 1 - 3 is true to the best of my knowledge. I understand and accept that I am responsible for full payment of my account and that payment is expected at the time of service. I also understand and accept that I am expected to notify WIOGS 24 hours prior to any cancellations or changes to my appointment times and that if I do not I may be charged for the appointment.

Signed: _____________________________________________________________________________________________________________ Date: ________________ Parent / Guardian (if applicable) ________________________________________________________________________________________

Copy of new-patient-information-form (1).pdf

Jaw tension or clicking (TMJ) Headache Nose bleeds Difficulty swallowing. Grinding teeth Migraine Headache Sneezing Lump or pit in throat. Frequent dental ...

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