docPrintable Women`s Intake Form
download 
Report Transcription
Printable Women`s Intake Form
We take your symptoms and an evaluation • WEIGHT of your entire endocrine system to ANTI-AGING • HORMONE BALANCING LOSS • NUTRITION determine how to treat you, as an individual. Please take the time to fill out the following forms and questionnaires before your visit, and bring them completed along with your insurance card. The questionnaires, although lengthy, help us identify the cause of your problems so that we can get you feeling better quicker. 6811 N. Knoxville Ave., Ste. A │ Peoria, IL 61614 2309 E. Empire St., Ste. 200 │ Bloomington, IL 61704 309.439.9400 309.740.7970 www.LifePlusMD.com © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION WOMEN’S INTAKE FORM Name: _________________________________________________________________________________ Address: _________________________________________________________________________________ City: ______________________________________ State: _________________ Zip: _____________ Home Phone: ___________________ Work Phone: _________________ Cell Phone: __________________ Email: ____________________________________________________________________________________ SSN#: _______________________ Date of Birth: _____ / _____ / _____ Age: ___________ Height: _____________________________________________ Weight: ___________________________________ Occupation: _____________________________________ Marital Status: ____________________________ Primary Insurance Information Employer: _________________________________________________________________________________ Company: _________________________________________________________________________________ Primary Address: ____________________________________________________________________________ Primary ID Number: _________________________________________________________________________ Primary Group ID: ____________________________________________________________________________ Primary Cardholder Information Name: _________________________________________________________________________________ Address: __________________________________________________________________________________ City: ______________________________________ State: _________________ Zip: _____________ SSN#: _______________________ Date of Birth: _____ / _____ / _____ Age: ___________ Secondary Insurance Information Secondary Address:_________________________________ Secondary ID Number:_______________________________ Secondary Group ID: ________________________________ ASSIGNMENT AND RELEASE I, the undersigned, verify that, to the best of my knowledge, the information above is correct. I assign directly to (Inspirit Health PC / LifePlus MD) all insurance benefits, if any, otherwise payable services are rendered. I understand that I am financially responsible for changes whether or not paid by insurance. By signing this form I fully understand that (Inspirit Health PC / LifePlus MD) is not a participant of Medicaid or Medicare and will not provide services to Medicaid or Medicare patients at this time. I hereby authorize release of information necessary to secure the payment of benefits. I authorize the use of this signature in all insurance submissions. _________________________________________________________________________________________ SignatureRelationshipDate © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION MESSAGE AUTHORIZATION Patient Name: __________________________________________ Date of Birth: _____ / _____ / _____ Please Circle Yes or No for the following questions: Do you give the staff at LifePlus MD permission to leave messages on your voice mail? YES NO If Yes, please specify phone number(s) we can leave voice mail: _______________________________________ Do you give the staff at LifePlus MD permission to send appointment reminders via text and email? YES NO Do you give the staff at LifePlus MD permission to discuss your healthcare needs with your spouse or other designated person? YES NO If yes, please list spouse/designated individuals and phone contacts: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ Signature Date © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION Primary Care and Specialty Doctors: Doctor’s Name: _____________________________________________________________________________ Location: __________________________________________________________________________________ Doctor’s Name: _____________________________________________________________________________ Location: __________________________________________________________________________________ Doctor’s Name: _____________________________________________________________________________ Location: __________________________________________________________________________________ Allergies: Pleae list all allergies to medications (if any) and what reactions have occurred (if any): __________________________________________________________________________________________ __________________________________________________________________________________________ Medications: Please list all prescription medications you currently take, including samples. Medication Name Dose Number of times per day Doctor 1. _______________________________________________________________________________________ 2. _______________________________________________________________________________________ 3. _______________________________________________________________________________________ 4. _______________________________________________________________________________________ 5. _______________________________________________________________________________________ 6. _______________________________________________________________________________________ 7. _______________________________________________________________________________________ Herbal/Supplements: Please list all vitamins, herbs, enzymes, protein supplements, pro-hormones or any other supplements. 1. _______________________________________________________________________________________ 2. _______________________________________________________________________________________ 3. _______________________________________________________________________________________ 4. _______________________________________________________________________________________ 5. _______________________________________________________________________________________ 6. _______________________________________________________________________________________ 7. _______________________________________________________________________________________ Past Medical History and Current Medical Conditions: Please check all that apply to you. Heart Disease Diabetes Cancer Epilepsy Hormone Related Issues Bladder Infections Blood Clots Diagnosed Obesity Lung Disease High Blood Pressure Depression Thyroid Disease Headaches Fatigue Abnormal PAP High Cholesterol Arthritis Ulcers Head Trauma Kidney Stones lnsomnia Prader-Willi Syndrome © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION List any other medical conditions that you currently receive treatment for (medical, chiropractor, physical therapist, etc.). _____________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Surgical History: ____________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Family History: Please list any illness that any of the following members of your family have had. Mother: ___________________________________________________________ Deceased q Yes q No Father: ____________________________________________________________ Deceased q Yes q No Siblings: ___________________________________________________________ Deceased q Yes q No Siblings: ___________________________________________________________ Deceased q Yes q No Children: ___________________________________________________________ Deceased q Yes q No Children: ___________________________________________________________ Deceased q Yes q No Gynecological History: Age of first period: ____________ Age of last period: ____________ Date of last PAP: ____________ Doctor/Location: _________________________________________________ Have you ever had an abnormal PAP? q Yes q No If yes, please elaborate? ______________________________________________________________________ Are you sexually active? q Yes q No Are you trying to get pregnant? q Yes q No Please list any birth control methods._____________________________________________________________ __________________________________________________________________________________________ Are your periods regular? q Yes q No Any abnormality with flow? q Yes q No Any cramps? q Yes q No Any premenstrual symptoms? q Yes q No Any fluctuations in timing of periods? q Yes q No Starting and ending when? _______________ Any bleeding between periods? q No Any pelvic pressure or fullness? q Yes When was your last period? _________________________ q No How many days do your periods last? _________________ Any unusual vaginal discharge or itching or recurrent urinary tract infections? q Yes q Yes q No Please describe: ____________________________________________________________________________ __________________________________________________________________________________________ Number of pregnancies: _________________________ Number of children: ____________________________ © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION Lifestyle Information: Do you use? If Yes, how often and how much? Tobacco (Chew, Smoke, Snuff) q Yes q No____________________________________ Alcoholq Yes q No____________________________________ Caffeine (Soda, Tea, Coffee) q Yes q No____________________________________ Artificial Sweeteners q Yes q No____________________________________ Do you snore or stop breathing when sleeping? q Yes Insomnia q Yes q No Sleep Apnea q Yes q No q No Diet: Do you have an eating plan that you follow? q Yes q No If Yes, please describe: _______________________________________________________________________ __________________________________________________________________________________________ Exercise: Do you exercise regularly? q Yes q No If Yes, how often and how much? _______________________________________________________________ __________________________________________________________________________________________ Stress Management: Do you practice any stress management techniques? q Yes q No If Yes, how often and how much? _______________________________________________________________ __________________________________________________________________________________________ Body Image: Are you comfortable with your current weight and size? Do you struggle to lose weight? q Yes q Yes q No q No General Health: Do you think your health is good? q Yes q No If No, please explain: ________________________________________________________________________ __________________________________________________________________________________________ Goals: What do you hope to accomplish at LifePlus MD? 1. _______________________________________________________________________________________ 2. _______________________________________________________________________________________ 3. _______________________________________________________________________________________ 4. _______________________________________________________________________________________ © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION Symptoms Report: Please indicate if the following symptoms apply to you. Headaches q Yes q No Painful Intercourse q Yes q No Decreased Libido q Yes q No Irritability q Yes q No Anxiety/Panic Attacks q Yes q No Weight Gain q Yes q No Breast Swelling q Yes q No Concentration Problems q Yes q No Breast Tenderness q Yes q No Shortness of breath q Yes q No Moodiness q Yes q No Night Sweats q Yes q No Foggy or Fuzzy Thoughts q Yes q No Inability to have orgasms q Yes q No Sleep Disturbances q Yes q No Fluid Retention q Yes q No Vaginal Dryness q Yes q No Breast Lumps or Fibroids q Yes q No Dry Hair/Skin q Yes q No Loss of sex drive q Yes q No Depression q Yes q No Bleeding Abnormalities q Yes q No Hair Loss q Yes q No Heat or Cold Intolerance q Yes q No Heart Palpitations q Yes q No Excessive Sweating q Yes q No Flushing or Hot Flashes q Yes q No Nervousness q Yes q No Frequent Yeast Infections q Yes q No Burned Out/Past Peak q Yes q No © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION Adrenal Function and Evaluation: Please indicate if the following statements apply to you. I have low blood pressure. ........................................................................................................................... I get dizzy or see spots when standing up rapidly from a sitting or lying position. ......................... I feel as though I might faint or black out. ................................................................................................ I have acute or chronic fatigue (lack of energy). .................................................................................... I have low energy before lunch or dinner. ................................................................................................ I usually feel better after 6pm. .................................................................................................................. I often feel the best late at night because I get a “second wind”. ...................................................... I have trouble getting asleep. ..................................................................................................................... I tend to wake early (approx. 3am - 5am) and have trouble getting back to sleep. .................... I need to rest after times of mental, physical, or emotional stress. ..................................................... I feel more tired after excercise or physical exertion, either soon after or the next day. ............. I have chronic tenderness in my back near the bottom of my rib cage. ............................................ I have back pain / joint pain / chronic inflammation. ........................................................................... I am allergic to many things, such as food, animals, and pollens. ....................................................... My allergies are getting worse. ................................................................................................................ I become hungry, confused, or shaky if I miss a meal. .......................................................................... I crave sugar, sweets, or desserts. ............................................................................................................. I use stimulants, such as tea or coffee, to get started in the morning. ............................................... I need caffeine (chocolate, tea, coffee, sodas) to get me through the day. ..................................... I often crave salt and/or foods high in salt, such as potato chips. .................................................... I do not eat regular meals. ....................................................................................................................... I have taken steroid medications for a long term or at high doses. ................................................. I have symptoms that improve after I eat. ............................................................................................ I get more than 2 colds or flus per year. ............................................................................................... I do not exercise regularly. ...................................................................................................................... I am emotionally stressed. ........................................................................................................................ I tend to be a perfectionist. ..................................................................................................................... I tend to avoid stressful situations for the sake of my health. ........................................................... I am less productive at work than I used to be. ................................................................................... My ability to focus mentally is generally impaired. ........................................................................... Stress causes me to become overly anxious. ........................................................................................ My sex drive is very low or non-existent. .............................................................................................. My relationships at work and/or home tend to be strained. ............................................................ My life contains insufficient time for fun and enjoyable activities. ................................................... I have little control over my life and I feel “stuck”. ............................................................................. I tend to get addicted easily to drugs, alcohol, or food. ................................................................... q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No © In Spirit Health PC | LifePlus MD www.LifePlusMD.com Peoria 309.439.9400 │ Bloomington 309.740.7970 ANTI-AGING • HORMONE BALANCING • WEIGHT LOSS • NUTRITION Adult Growth Hormone Deficiency Assessment: Please indicate if the following statements apply to you. I struggle to finish jobs. ................................................................................................................................ I feel a strong need to sleep during the day. ......................................................................................... I often feel lonely even when I am with other people. ......................................................................... I have to read things several times before they sink in. ....................................................................... It is difficult for me to make friends and/or hard for me to mix with people. ................................. It takes a lot of effort for me to do simple tasks. .................................................................................. I have difficulty controlling my emotions. ................................................................................................. I often lose track of what I want to say, or forget what people say to me. ..................................... I lack confidence. .......................................................................................................................................... I have to push myself to do things. ........................................................................................................... I often feel very tense. ................................................................................................................................ I feel as if I let people down. .................................................................................................................... I feel worn out even when I’m not doing anything. ................................................................................ There are times I feel very low. ................................................................................................................ I avoid responsibility if possible. .............................................................................................................. I avoid mixing with people I don’t know well. ....................................................................................... I feel as if I am a burden to people. ...................................................................................................... I find it difficult to plan ahead. ................................................................................................................ I have to force myself to do things that need doing. .......................................................................... My memory lets me down. ....................................................................................................................... q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No q No Thyroid Function and Evaluation Tool: Please indicate if the following statements apply to you. Do you feel exhausted from morning to night? ..................................................................................... Do you have trouble getting up in the morning? ................................................................................... Do you have morning stiffness? ................................................................................................................ Do you have trouble working under pressure? ...................................................................................... Do you have trouble losing weight no matter what you do? ............................................................... Are you constipated? ................................................................................................................................... Do your muscles feel weak as if they can’t generate energy? ........................................................... Is your cholesterol over 200? .................................................................................................................... Do you have or did you have PMS or menstrual difficulty? ................................................................ Have you ever had trouble with fertility? ............................................................................................... Do you have low body temperature? ...................................................................................................... Do you use any sort of thyroid supplementation?.................................................................................. Do you have a history of anemia or bruise easily? .............................................................................. q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q Yes q No q No q No q No q No q No q No q No q No q No q No q No q No © In Spirit Health PC | LifePlus MD
