NEW PATIENT PERSONAL INFORMATION_documents/history_2016_pub_w… · REVIEW OF SYSTEMS: Skin: Acne Dry Liver Spots Rash White Bumps Ridged Nails Athlete’s Foot Eczema Oily Redness

Aug 2019 www.ChelationMedicalCenter.com

NEW PATIENT PERSONAL INFORMATION www.ChelationMedicalCenter.com

Patient’s full name: ___________________________________ Today’s date: ___/___ /___

Address: _______________________________________ Birth date ____/____/____ Sex: M / F

City: ________________________________________ State: _____ Zip: ___________

Home phone: (_____) ____________________ Work: (_____) ____________________

Cell: (_____) ____________________ Permission to text message? __ YES ___ NO

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. We do not accept Payments from third parties

such as Insurance companies, Medicare or Maine Care.

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: ___/___ /____

http://www.chelationmedicalcenter.com/

Apr 2019 www.ChelationMedicalCenter.com Page 1 of 11

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)

Past Present How severe How Frequent

1. Headaches

2. Problems with vision, hearing, taste or smell

3. Chest Pain or shortness of breath

4. Cough, wheezing or other difficulties

5. Heartburn, gas, bloating, indigestion

6. Constipation, diarrhea, hemorrhoids

7. Urinary tract problems, stones, infections in the bladder or kidney

8. Gynecologic problems(specify)

9. Infertility, impotence, low libido

10. Skin or hair problems

11. Bone or joint disorders

12. Neurological problems, Fasciculations

13. Mood, emotion, or psychiatric problems

14. Fatigue, night sweats, loss of motivation

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


MEDICATIONS & NUTRITIONAL SUPPLEMENTS

Medications: Include all prescription and over the counter medications that you are currently taking

Prescription medications Dose How often taken

Nutritional supplements: Include all vitamins, minerals, herbals & other supplements that you are currently taking (attach extra page if necessary) Name Manufacturer Dosage and Frequency Office use only

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? __________

Hormone medications Name: _____________________ Duration: _________ When stopped? __________

Other long term prescription drugs you have taken in the past:

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? ________________________

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:

Daily Weekly Occasionally Never Past

Coffee/caffeine

Aspirin

Laxatives

Exercise

Meditation

REVIEW OF SYSTEMS:

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

Gums

Crowns Freq Sore

Throats

Gold Fillings Infections Metal Braces Sore Tongue


Respiratory: Apnea Bronchitis Difficulty Breathing Pleurisy Shortness in Breath Smoke: Y or N

Asthma Congestion Cough Pneumonia Wheeze 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

Pain

Bloating Difficulty

Swallowing

Gall Bladder

Removed

Irritable

Bowel

Nausea Ulcers

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

Genital (male): Discharge Impotence Itching Prostatic Hypertrophy Testicular Pain

Genital Herpes Infertility Painful Urination Sores Infection

Genital (female): Birth Control

Pills

Excess Hair

Growth

Genital Herpes Infertility Menopausal

Symptoms

Tender Breasts

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

Gait

Excessive

Sleepiness

Poor

Coordination

Learning

Problems

Poor Dream

Recall

Shaky Feeling Unprovoked

Anger

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: 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 Blood Transfusion

Breast Implants CFS Hx Infection Lyme Hx Swollen Glands

Allergic to

everything

Chronic

Fatigue

Chemical Intolerance Dental Implants Universal Reactor


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 _______________________

ILLNESSES & DISEASES (Past Medical History):

Date of last complete checkup _____________ Results _______________________________

Names of recent Doctors consulted ________________________________________________

Have you had adjustments or other treatments for your neck or back? Yes No

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.):

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? ________________


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

WORK HISTORY & ENVIRONMENT

Current Occupation: ____________________________________ How Long? _______________

Past Occupations: ______________________________________ How long? _______________

_____________________________________ How long? _______________

_____________________________________ How long? _______________


HOME ENVIRONMENT



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 in your home? Which one?

___________________________________________________________________________________

___________________________________________________________________________________

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? __________ Natural Dentist? ________


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 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

High Protein Always

Dieting

No Meat Diet High Beef Diet Avoid

Vegetables

Food Over consumption

EPD Diet Wheat Free Heavy Alcohol French Fries Avoid Salads Microwave used

Dietary Intake: (Circle Low (L), Medium (M), or High (H) intake For only those that pertain! 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

Sunflower Oil L M H Peanut Oil L M H Mayonnaise L M H Miracle Whip

Walnut Oil L M H Corn Oil L M H Margarine L M H Kraft

Olive Oil L M H Mineral Oil L M H Butter L M H Mazola

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 ______


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 to improve your health? Yes No

What are your goals to improve your health? ______________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

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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!

Documents

NEW PATIENT PERSONAL INFORMATION_documents/history_2016_pub_w… · REVIEW OF SYSTEMS: Skin: Acne Dry Liver Spots Rash White Bumps Ridged Nails Athlete’s Foot Eczema Oily Redness