patient questionairre form

NEW PATIENT PERSONAL INFORMATION
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Patient’s full name: ___________________________________ Today’s date: ___/___ /___
Address: _______________________________________
_______________________________________
Birth date ____/____/____ Sex: M / F
Age: ____ marital status _________
Home phone: (____) ____________ Work: (____) _____________ Cell: ___________________
E-Mail ______________________________________ SSN (optional) __________________
Spouse's or Parent’s name(s) ____________________________________________________
Who referred you or how did you hear about us? ______________________________________
FINANCIAL INFORMATION: responsible party name: __________________________________
Relationship ___________ address (if different) ___________________________________
IN CASE OF EMERGENCY NOTIFY: _______________________ Phone (____)____________
Payment for Services:
Payment is due at the time services are rendered. Insurance filing is the responsibility of the
patient/guardian. We will provide a billing statement receipt for you with diagnostic and procedural
codes which you may submit to your insurance provider. We do not accept Medicare or MaineCare
assignment of benefits.
Primary Care Doctor: ______________________________ phone # ____________________
We recommend that our patients have a primary care physician for routine problems, acute illness
and hospital admissions. If you agree to have Dr. Psonak discuss medical issues with your primary
care doctor, sign here: ___________________________________ date: ___/___/___
I UNDERSTAND that the approach of Chelation Medical Center, LLC and Dr. Psonak to medical
problems is from a perspective that may differ from what may be considered the conventional or
standard therapy of the medical community.
I also understand that the office is fragrance free. Anyone entering the office must avoid the use
of perfume, after-shave, fragrances or residue of smoke on their clothes, otherwise they will
be asked to leave and another appointment will be set for them. Please ask if you should
come in fasting for your visit.
Patient or Guardian Signature: ____________________________________ Date: ___/___ /____
Aug 2014
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Medical History
Today’s Date __________________
Patient Name _____________________________________ Date of Birth _________________
Your Height: _____________ Your Weight: ______________
Main Problems (Chief Complaint):
List the main problems that you wish to address - current medical problems/date started
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
YOUR SYMPTOMS (History of Main Problems):
Please list any symptoms that you have now or experienced: (Please check past or present
and how severe and frequent the problem)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Headaches
Problems with vision, hearing, taste or
smell
Chest Pain or shortness of breath
Cough, wheezing or other difficulties
Heartburn, gas, bloating, indigestion
Constipation, diarrhea, hemorrhoids
Urinary tract problems, stones,
infections in the bladder or kidney
Gynecologic problems(specify)
Infertility, impotence, low libido
Skin or hair problems
Bone or joint disorders
Neurological problems, Fasciculations
Mood, emotion, or psychiatric problems
Fatigue, night sweats, loss of motivation
Past
Present
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
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
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

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How severe
How Frequent
Allergies or adverse drug reactions: (List Known Allergies to medication and type of reactions)
___________________________________________________________________________________
___________________________________________________________________________________
Other Allergies: Check all that apply:
 Dairy  Wheat  Corn  Eggs  Peanuts  shellfish  Chemicals  DON’T KNOW
Do you react to pollen?  Yes  No
Reaction __________________________
Do you react to molds?  Yes  No
Reaction __________________________
Do you react to foods?  Yes  No
Reaction __________________________
Blood Type: Do you know your blood type? (Circle One) O A B AB (Circle One) Positive or Negative
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MEDICATIONS:
Prescription medications
Dose
How long have you been on them?
HISTORY OF MEDICATIONS TAKEN IN THE PAST:
Have you ever taken any of the following medications?
Lipid lowering (Statins, etc.) Name: _____________________ Duration: _________ When stopped? __________
Osteoporosis (Phosomax, etc.) Name: ___________________ Duration: _________ When stopped? __________
Antibiotics
Name: _____________________ Duration: _________ When stopped? __________
Birth Control medications
Name: _____________________ Duration: _________ When stopped? __________
Other long term prescription drugs:
Name: ___________________________ Duration: _____________ When stopped? _____________
Name: ___________________________ Duration: _____________ When stopped? _____________
Name: ___________________________ Duration: _____________ When stopped? _____________
Date of last medical checkup _________ Results ________________________________
Names of recent Doctors consulted ___________________________________________
Have you had adjustments or other treatments for your neck or back?  Yes  No
Habits:
Do you smoke? No__ Yes__ If yes, how many packs per day? _____________________
If you have quit, how long ago? _________ How many years did you smoke? ____
Do you use alcohol?
No__ Yes__ If yes, how often do you drink?__________________
Do family or friends worry about your alcohol intake? _________
Have you ever had problems with drug use?__________________
Please indicate past or present amounts of the following:
Daily
Weekly
Occasionally
Never
Past
Coffee/caffeine
Aspirin
Laxatives
Exercise
Meditation
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NUTRITIONAL SUPPLEMENTS:
Please list all vitamins and supplements that you are taking (attach extra page if necessary).
Name
Manufacturer
Dosage and Frequency
Office use only
REVIEW OF SYSTEMS (Current symptoms only):
Skin:
 Acne

Dry

Liver Spots

Rash
 White Bumps
 Ridged Nails
 Athlete’s Foot

Eczema

Oily

Redness
 White Patches
 Spoon Shaped Nails
 Bruising

Hair Loss

Pale

Rough
 Yellow Tone
 White Spots on Nails
 Burning Feet

Herpes

Peeling

Skin Tags
 Bluish Lips
 Cracks

Hives

Poor Wound Healing

Vitiligo
 Deep Red Lips
 Dandruff

Itching

Psoriasis

Warts
 Pale Lips
Eyes:
 Bags Under
 Cataracts
 Diplopia
 Floaters
 Light Sensitive  Sclera blue

Swollen Lids
 Blurred Vision
 Crusty Lids
 Discharge
 Freq. Blinking
 Pain
 Sclera White

Tearing
 Burning
 Dark Circles
 Dyslexia
 Glaucoma
 Bloodshot
 Styes
Ears:
 Discharge
 Excessive Wax

Infection
 Red Ear Lobes

Sound Sensitive

Vertigo
 Ear aches
 Hearing Loss

Itching
 Ringing

Tinnitus

Pressure
Nose & Sinuses:
 Crusts
 Freq. Colds
 Itching
 Nose Bleeds

Sinus Trouble

Stuffiness
 Discharge
 Hayfever
 Mucus Yellow
 Polyps

Sneezing

Asthma HX
Mouth & Throat:
 Amalgams
 Canker Sores
 Silver Fillings
 Gag Easily
 Grind Teeth  Lines on Tongue
 Mouth Ulcers
 Bad Breath
 Chapped Lips
 Dentures
 Gingivitis
 Hoarseness
 Lips Crack
 Red Tip Tongue
 Bridges
 Coated Tongue
 Drooling
 Glossy Tongue
 Implants
 Magenta Tongue
 Root Canals
 Bleeding
 Crowns
 Freq Sore
 Gold Fillings
 Infections
 Metal Braces
 Sore Tongue
Gums
Throats
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Respiratory:

Apnea

Bronchitis
 Difficulty Breathing
 Pleurisy
 Shortness in Breath

Asthma

Congestion
 Cough
 Pneumonia
 Wheeze
 Smoke: Y or N
Packs per Day __________
Cardiac:
 Cold Extremities
 Dyspnea
 Flushing of Skin
 High B/P
 Palpitations
 Atherosclerosis: Y/N _______
 Chest Pain
 Edema
 Heart Murmur
 Low B/P
 Tight Chest
 HX of Heart Surgery _____________
Gastrointestinal:
How often do you have a bowel movement? ______________ What is color of stool? _____
 Abdominal
 Bloating
 Difficulty
Pain
 Gall Bladder
Swallowing
 Irritable
Removed
 Nausea
 Ulcers
Bowel
 Anal Itching
 Colitis
 Diarrhea
 Heartburn
 Ingestion
 Regurgitation
 Vomiting
 Belching
 Constipation
 Flatulence
 Hemorrhoids
 Mucus
 Tan Stool
 Fat intolerance
Urinary:
 Burning
 Frequency
 Incontinence

Kidney Disease

Polyuria
 Urgency
 Dark Yellow Urine
 Cystitis
 Hesitancy
 Infections

Nocturia

Stones
 Pale Urine
Prostatic Hypertrophy

Testicular Pain
Sores

Infection
Genital (male):
 Discharge
 Impotence
 Itching

 Genital Herpes
 Infertility
 Painful Urination

Genital (female):
 Birth Control
 Excess Hair
Pills
 Genital Herpes
 Infertility

Menopausal
Growth
 Tender Breasts
Symptoms
 Discharge
 Endometriosis
 Hot Flashes
 Irregular Cycle

PMS
 Yeast Infections
 Dysmenorrhea
 Low Libido
 Hysterectomy
 Itching

Spotting
 Excess Bleeding
Musculoskeletal:
 Arthritis
 CP
 Hx of Fractures
 Joint Swelling
 Muscle Weakness

Spasticity
 Atrophy
 Fibromyalgia
 Hypotonia
 Limited Range/Motion
 Rigidity

Stiffness
 Backache
 Gout
 Joint Pain
 Muscle Pain
 Spasms

Uneven Muscular
Development
Neurologic:
 Abnormal
 Excessive
 Poor
 Learning
 Poor Dream
 Unprovoked
Gait
Sleepiness
Coordination
 ADD
 Delusional
 Hyperactivity
 Mood Swings
 Poor Memory
 Speech Delay
 Weakness
 ADHD
 Depression
 Impulsiveness
 Nervousness
 Rage Behavior
 Tension
 Withdrawal
 Anxiety
 Disoriented
 Insomnia
 Nightmares
 Restlessness
 Tics
 Autistic Features
 Apathy
 Confusion
 Irritable
 Numbness
 Sciatica
 Tingling
 Fasciculation
 Brain Fog
 Fainting
 Headaches
 PDD
 Seizures
 Tremors
 Unable to Walk
Endocrine:
Problems
 Shaky Feeling
Recall
Anger
 Coarse Features
 Cold Intolerance
 Excessive Thirst
 HRT
 Hypothyroid
 Underweight
 Edema
 Excessive Hunger
 Fatigue
 Hyperthyroid
 Carb Intolerance
 Diabetes Hx
 Dysinsulism
 Excessive Swelling
 Heat Intolerance
 Hypoglycemia
 Overweight
Immune:
 Autoimmune
 Cancer Hx
 Hepatitis Hx
 Lupus
 Recurrent Illness
 Breast Implants
 CFS Hx
 Infection
 Lyme Hx
 Swollen Glands
 Allergic to
 Chronic
 Chemical Intolerance
 Dental Implants
 Universal Reactor
everything
Fatigue
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 Blood Transfusion
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WOMEN ONLY
Number of children ____ Ages/Gender _________________________________________ Adopted______
Number of: Pregnancies _____ Deliveries ______ Miscarriages _____ Abortions _____
Do you use a contraceptive?
 Yes  No If so, what type _________________________________
Last Pap smear _____________ Result ____________ Last mammogram ____________ Result _________
Have you had a scan DEXA for bone density?  Yes  No
Result _______________________________
Are you taking hormone replacement therapy?  Yes  No What form? ___________________________
Social History:
Please list all countries you have traveled to or lived in the past:
___________________________________________________________________________________
___________________________________________________________________________________
Where was your place of birth? _____________________________________________
States where you lived in the past: __________________________________________
Does your spiritual life play an important role in your life?  Yes  No
First Partnered ____ Number of years ____
Divorced/separated _____ When ____
Number of children ____ Ages/Gender _______________________
TRAUMATIC EVENTS (Past Medical History):
Please list all Accidents and Injuries:
Please list any surgeries (operations), reason for the surgery, and date of surgery:
Please list other diseases from which you currently suffer or have suffered if not already described:
Please list other traumatic events: (for example, loss of close relationships by death, illnesses, divorce;
major life changing events, major moves, major job changes, etc.):
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FAMILY HISTORY: Place an “X” in appropriate boxes to identify all illnesses/conditions in your blood relatives
Illness/Condition
Family Member
grandparents
father
mother
brother
sister
son
daughter
other
Allergies
Asthma
Cancer (specify)
Heart disease
Stroke
Lung disease (specify)
Diabetes
High blood pressure
Liver disease
High cholesterol
Alcohol/drug abuse
Neurologic disease
(specify)
Depression/psychiatric
illness
Genetic (inherited)
disorder
Other
ENVIRONMENTAL EXPOSURES
HOBBIES / SPORTS: ______________________________________________________________
___________________________________________________________________________________
List any chemicals, metals, dusts, molds, or fumes to which you are repeatedly exposed
___________________________________________________________________________________
___________________________________________________________________________________
Do you have or have you had a toxic exposure such as mold, Radon, lead, Uranium, pesticide
fumigation sprays, etc. in your home? Please explain?
___________________________________________________________________________________
___________________________________________________________________________________
Do you see a dentist regularly?________ Name of Dentist: __________________________________
How many silver fillings did you have? ____ How many silver fillings do you have now? _____
How many root canals do you have? _______ Any tooth implants? __________
Have you had your fillings removed? _____ When? __________ Done by Natural Dentist? ________
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WORK HISTORY & ENVIRONMENT
Current Occupation: ____________________________________ How Long? _______________
Past Occupations: ______________________________________ How long? _______________
______________________________________ How long? _______________
______________________________________ How long? _______________
HOME ENVIRONMENT
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DIET HISTORY:
1. Do you follow a special diet?  Yes  No
Organic certified?  Yes  No
2. What is your primary source of water? (Circle One) Tap City Well Bottled Filtered
3. How often do you consume fish per week? _______
4. What kinds of fish do you eat?________________________________________
5. How many slices of bread do you eat daily?________ Kind of Bread?_________
6. How many glasses of milk daily?_____ Kind of milk consumed?______________
7. How many cups of coffee per day? _____ Decaf _____ Regular _____ Organic
8. How many cups of tea per day? _____ Decaf _____ Regular _____ Organic
9. Is margarine or butter used most of the time?____________________________
10. What kind of oil do you cook with? ____________________________________
11. Are most meals consumed at home, restaurants or fast food?________________
12. Are sugar substitutes used? _________ Which ones?_______________________
13. Are you or have you ever been a vegetarian?______________________________
14. Do you eat wild local game (venison)?___________________________________
15. Were you breast fed? _________ How long? _____________________________
16. What are your favorite deserts?________________________________________
17. What is your favorite food?____________________________________________
18. List foods you do not like _____________________________________________
19. Do you shop in a health food store? _____ What percent of the time?__________
20. What percentage of the food you eat is organic? _____ %
Diet Hx: (Check all that apply)
 Low Fat
 Vegetarian
 Generally Good Diet
 Diet Soda
 High Juice intake  Crave Bacon & Lunch Meat
 Low Carb
 Rotation Diet
 Gluten Free Diet
 Nutrasweet
 Love ice cream
 Love Donuts
 High Carb
 Atkins Diet
 Allergy Free Diet
 High Caffeine
 Love milk
 High Sugar Intake
 High Fat Diet
 Zone Diet
 Milk/Casein Free Diet  Enteral Feed
 Restrict Salt
 Crave Non-edibles
 Low Protein
 Ketogenic
 High Bread/Pasta
 Poor Food Choices
 Avoid Butter
 Avoid Eating
 Hgh Protein
 Always
 No Meat Diet
 High Beef Diet
 Avoid
 Food Over consumption
Dieting
 EPD Diet
Vegetables
 Wheat Free
Dietary Intake: (Circle Low
 Heavy Alcohol
 French Fries
 Avoid Salads
(L), Medium (M), or High (H) intake For only those that pertain!
 Microwave used
Brand Names Used:
Sesame Oil
L M H
MCT Oil
L M H
Lard
L M H

Wesson
Safflower Oil
L M H
Soy Oil
L M H
Crisco
L M H

Best Foods
Flax Oil
L M H
Cottonseed Oil
L M H
Salad Dressing
L M H

Hellmann’s
Miracle Whip
Sunflower Oil
L M H
Peanut Oil
L M H
Mayonnaise
L M H

Walnut Oil
L M H
Corn Oil
L M H
Margarine
L M H

Kraft

Mazola
Olive Oil
L M H
Mineral Oil
L M H
Butter
L M H
Canola Oil
L M H
Mustard Oil
L M H
Coconut Butter
L M H
 Other ___________________________
Daily Fluid Consumption:
Fluid Intake: _____ Cups of Water _____ Cups of Juice _____ Cups of Milk _____ Cans of Soda _____ Cups of Coffee/Tea ______
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DIETARY HISTORY FORM
PLEASE FILL OUT THE FOLLOWING WITH WHAT YOUR DIET TYPICALLY CONSISTS OF ON AN AVERAGE DAY.
PLEASE BE AS SPECIFIC (AND HONEST) AS POSSIBLE!
BREAKFAST: _________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SNACK: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
LUNCH: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SNACK: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
DINNER: ____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SNACK: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Are you willing to change your lifestyle/habits/diet to improve your health?  Yes  No
What are your goals to improve your health? ______________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
***************************************************
Thank you for taking the time to complete this form.
PLEASE BE SURE TO BRING THIS COMPLETED QUESTIONNAIRE TO YOUR APPOINTMENT
It is the beginning of your process of healing and good health!
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