KINGWOOD HEALTH & WELLNESS CLINIC

REGISTRATION FORM

(Please Print)

Today’s date:

PCP:

PATIENT INFORMATION

We verify your identity with your Drivers License

Patient’s last name:

First:

Middle:

 Mr.

 Mrs.

 Miss

 Ms.

Marital status (circle one)

Single / Mar / Div / Sep / Wid

Is this your legal name?

If not, what is your legal name?

(Former name):

Birth date:

Age:

Sex:

 Yes

 No

/ /

 M

 F

Street address:

DL #

Home phone no.:

( )

P.O. box:

City:

State:

ZIP Code:

Occupation:

Employer:

Employer phone no.:

( )

Chose clinic because/Referred to clinic by (please check one box):

 Dr.

 Business Card

 Billboard

196059

 Internet

 Family

 Friend

 Newspaper

 Yellow Pages

Other family members seen here:

Advance Beneficiary Notice of Noncoverage

I hereby certify that the above information is true and correct to the best of my knowledge. I hereby authorize The Health & Wellness clinic to release any of my patient information required for continued care to other Providers that I may utilize for my care. I understand and agree, that I am financially responsible for any ;balance ;owed for my care. Further, I understand that Medicare/Insurance may not cover services rendered and that The Health & Wellness Clinic WILL NOT be providing me with any documentation for third party billing/reimbursement purposes, including but not limited to Medicare, Medicaid or Private Pay Insurance. Finally, I understand that The Health & Wellness Clinic WILL NOT be submitting any claims, claim documents, or supporting records to any third party on my behalf.

;

Patient/Guardian signature

Date

REASON FOR VISIT TODAY
Please check the reason you are coming in today; if it is not listed please write in the reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________		#9633; New weight patient □ Weight follow-up □ B-complex Injection □ Lab Consult □ Lab to be done □ Office visit □ Botox Injections □ Mesotherapy		□ Hormone Imbalance □ High blood pressure □ Loss of sexual desire □ Diabetes □ Headaches □ Depression □ Microderm Abrasion
		¨ Thyroid Visit
PHILOSOPHY We strive to achieve optimal health & wellness through nutrition, exercise, hormone balance and optimization. Our programs and protocols are designed to maximize your QUALITY of life. If your hormone levels are in a “normal” range but are low and you have symptoms we may start therapy to alleviate symptoms. Please sign below to indicate that you understand and consent to treatment.

	Patient/Guardian signature		Date

(Patient MUST read and sign in order to be seen)

Original Date:

05/01/2006

Dates Revised: 01/01/2009

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.

Name (Last, First, M.I.):

 M  F

DOB:

Marital status:

 Single  Partnered  Married  Separated  Divorced  Widowed

Previous or referring doctor:

Date of last physical exam:

PERSONAL HEALTH HISTORY

Childhood illness:

 Measles  Mumps  Rubella  Chickenpox  Rheumatic Fever  Polio

Immunizations and dates:

 Tetanus

 Pneumonia

 Hepatitis

 Chickenpox

 Influenza

 MMR Measles, Mumps, Rubella

List or circle any medical problems that other doctors have diagnosed

 Low thyroid  Cancer High Thyroid

 High blood pressure  Depression

 High Cholesterol  Bipolar

 Diabetes (insulin or no-insulin)  Reflux

Surgeries  No Surgeries Please list or circle if listed

Year

Surgery

Thyroidectomy R Left Total

 C-section How many?______________

Gastric  Staple or  Banding

 Hysterectomy  Tubal Ligation

Heart Surgery

 Gallbladder removed (cholecystectomy)

Other:

 Appendectomy

Other:

 Tonsillectomy

Other:

Other hospitalizations

Year

Reason

Age if you do not remember year

Have you ever had a blood transfusion?



Yes



Please turn to next page

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List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug			Strength			Frequency Taken








Allergies to medications  No Known Drug Allergies
Name the Drug			Reaction You Had




HEALTH HABITS AND PERSONAL SAFETY

Please answer All questions contained in this questionnaire all answers will be kept strictly confidential.
Exercise	 Sedentary (No exercise)
	 Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
	 Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
	 Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet	Are you dieting ?								Yes		No
	Have you taken appetite suppressants in the past? If so what medication?_________________________								Yes		No
	# of meals you eat in an average day?
	Rank salt intake	 Hi		 Med	 Low
	Rank fat intake	 Hi		 Med	 Low
Caffeine	 None	 Coffee		 Tea	 Cola
	# of cups/cans per day?
Alcohol	Do you drink alcohol?								Yes		No
	If yes, what kind? beer wine liquor
	How many drinks per week?





Tobacco	Do you use tobacco?								Yes		No
	 Cigarettes – pks./day			 Chew - #/day	 Pipe - #/day		 Cigars - #/day
	 # of years	 Or year quit  Do you desire to quit?______________
Drugs	Do you currently use recreational or street drugs?								Yes		No

Sex	Are you sexually active?								Yes		No
	If yes, are you trying for a pregnancy?								Yes		No
	If not trying for a pregnancy list contraceptive or barrier method used:
	Any discomfort with intercourse?								Yes		No
	Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
									Yes		No
Personal Safety	Do you live alone?								Yes		No
	Do you have frequent falls?								Yes		No
	Do you have vision or hearing loss?								Yes		No
	Do you have an Advance Directive or Living Will?								Yes		No

FAMILY HEALTH HISTORY

	Age	Significant Health Problems		Age	Significant Health Problems
Father (F)			Children (M)male (F)female	 M  F
Mother (M)
Diabetes Heart Disease Hypertension Thyroid Kidney	 M  F
				 M  F
				 M  F
				 M  F
	 M  F
	 M  F		Grandmother Maternal
	 M  F		Grandfather Maternal
	 M  F		Grandmother Paternal
	 M  F		Grandfather Paternal

Fatigue Symptoms

Do you have problems with weight gain or losing weight?		Yes		No
Do you occasionally feel depressed or have depressed moods?		Yes		No
Is your concentration decreased?		Yes		No
Do you have problems with occasional constipation?		Yes		No
Do you get cold easily or have cold hands or feet?		Yes		No
Have you noticed excessive hair loss?		Yes		No
Is your skin dry?		Yes		No
Do you have trouble sleeping?		Yes		No
Poor energy or fatigue?		Yes		No
Bone / Joint Pain		Yes		No

WOMEN ONLY

Age at onset of menstruation:
Date of last menstruation:
Period every _____ days Length of periods_______days
Heavy periods, irregularity, spotting, pain, or discharge?		Yes		No
Number of pregnancies _____ Number of live births _____ Miscarriage_______Abortions_____
Are you pregnant or breastfeeding?		Yes		No
Have you had a D&C, hysterectomy, or Cesarean?		Yes		No
Any urinary tract, bladder, or kidney infections within the last year?		Yes		No
Any blood in your urine?		Yes		No
Any problems with control of urination?		Yes		No
Any hot flashes or sweating at night?		Yes		No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?		Yes		No
Experienced any recent breast tenderness, lumps, or nipple discharge?		Yes		No
Do you usually get up to urinate during the night?		Yes		No
If yes, # of times _____
Date of last pap and rectal exam? Results:  Normal  Abnormal (Please list any findings)
Date of last mammogram?___________Results:  Normal  Abnormal (Please list any findings)
MEN ONLY
Do you usually get up to urinate during the night?		Yes		No
If yes, # of times _____
Do you feel pain or burning with urination?		Yes		No
Any blood in your urine?		Yes		No
Do you feel burning discharge from penis?		Yes		No
Has the force of your urination decreased?		Yes		No
Have you had any kidney, bladder, or prostate infections within the last 12 months?		Yes		No
Do you have any problems emptying your bladder completely?		Yes		No
Any difficulty with erection or ejaculation?		Yes		No
Any testicle pain or swelling?		Yes		No
Date of last prostate and rectal exam? Results:  Normal  Abnormal (Please list any findings)		Yes		No
OTHER PROBLEMS

Check if you have, or have had any symptoms in the following areas to a significant degree and briefly explain.

	Skin		Chest/Heart		Recent changes in:
	Head/Neck		Back		Weight
	Ears		Intestinal		Energy level
	Nose		Bladder		Ability to sleep
	Throat		Bowel		Other pain/discomfort:
	Lungs		Circulation		Hormonal symptoms

KINGWOOD HEALTH & WELLNESS CLINIC

REGISTRATION FORM

PATIENT INFORMATION

Advance Beneficiary Notice of Noncoverage

REASON FOR VISIT TODAY

Original Date:

Dates Revised: 01/01/2009

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidentialand will become part of your medical record.

DOB:

Marital status:

Previous or referring doctor:

Date of last physical exam:

PERSONAL HEALTH HISTORY

Childhood illness:

Immunizations and dates:

List or circle any medical problems that other doctors have diagnosed

Surgeries  No Surgeries Please list or circle if listed

Other hospitalizations

Have you ever had a blood transfusion?

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Allergies to medications  No Known Drug Allergies

HEALTH HABITS AND PERSONAL SAFETY

Exercise

Diet

Caffeine

Alcohol

Tobacco

Drugs

Sex

Personal Safety

FAMILY HEALTH HISTORY

Father (F)

Children

Mother (M)

Diabetes

Grandmother

Grandfather

Grandmother

Grandfather

Fatigue Symptoms

WOMEN ONLY

MEN ONLY

OTHER PROBLEMS

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.