New Patient Assessment Form
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- Madeleine Greer
- 7 years ago
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1 One s health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of your ability to give us an overall view of your general lifestyle and health habits. New Patient Assessment Form First Name Middle Name Last Name Address City State Zip Please indicate your preferred method of contact (Please circle): home work cell Home Phone ( ) - Birth Date / / Age Work Phone ( ) - Address: Cell Phone ( ) - Height Weight Sex Blood Type (Please circle): A/ AB/ B/ O/ Unk Occupation Marital Status Do you have children? Yes No Age of children Are you pregnant? Yes No Due date With whom do you live? (Include children, parents, relatives, and/or friends; ages) Example: Sarah, age 7, sister Primary Care Provider Date of last physical exam Other doctors or practitioners you see Would you like to receive notifications regarding how to live healthy? If yes, please sign 1
2 Past Medical and Surgical History Please indicate whether you or your relatives* have been diagnosed with any of the following diseases or symptoms (specify which relative and date of diagnosis) *Relatives include: parents, grandparents, siblings. Illness/Disease/Symptom Allergies (specify type of allergy) Anemia Anxiety or Panic Attacks Arthritis (osteoarthritis or rheumatoid) Asthma Autoimmune conditions (specific type) Bronchitis Cancer Chronic Fatigue Syndrome Crohn s Disease or Ulcerative Colitis Depression Diabetes (specify: Type I, II, Prediabetes, Gestational) Dry / Itchy skin, Rashes, Dermatitis Eczema Emphysema Epilepsy, Convulsions, or Seizures Eye Disease (specify) Fibromyalgia Food Allergies or Sensitivities Fungal Infection (athlete s foot, ringworm, other) Gallbladder Disease/Gallstones (specify) Grout Heart Attack/Angina Heartburn Heart Disease (specify) Hepatitis High blood fats (cholesterol, triglycerides) High blood pressure (hypertension) Hypoglycemia (low blood sugar) Intestinal Disease (specify) Inflammatory Bowel Disease (Crohn s or Ulcerative Colitis) Irritable Bowel Syndrome Kidney Disease/failure or Kidney stone Lung Disease (specify) Liver Disease Mononucleosis Self: Age Diagnosed Relative: Age Diagnosed Describe/Specify 2
3 Illness/Disease/Symptom Self: Age Diagnosed Relative: Age Diagnosed Osteoporosis PMS Polycystic Ovarian Syndrome Pneumonia Prostate Problems Psychiatric Conditions Seizures or Epilepsy Sinusitis Sleep apnea Stroke Thyroid Disease (hypo- or hyperthyroid) Urinary Tract Infection Other (describe) Injuries Age Describe/Specify Back injury Broken (specify) Head injury Neck injury Other (describe) Diagnostic Studies Age at study Describe/Specify Barium Enema Bone Scan CAT Scan: abdomen, brain, spine (specify) Chest X-ray Colonoscopy or Sigmoidoscopy (specify) EKG Liver Scan NMR/MRI Upper GI Series Other (describe) Operations Age at operation Describe/Specify Dental surgery Gall Bladder Hernia Hysterectomy Tonsillectomy Other (describe) Describe/Specify 3
4 Medication, Supplement, and Antibiotic Intake Please provide the names of any medications, supplements and/or antibiotics and the dosage you are currently taking. Medication/Supplement/ Antibiotic Example: One-a-Day (brand) Men s Multivitamin Dose Units Frequency Start Date Stop Date 1200 Mg Daily 08/12/2007 Current Are you allergic to any medications? Yes No Please list: 4
5 Lifestyle: Social support and readiness for change Physical activity: Using the table, please describe your physical activity Activity Stretching/Yoga Cardio/Aerobics (walking, jogging, biking, etc.) Strength-training (weight lifting, pilates, some yoga) Sports or Leisure Other (specify/describe) Type/Intensity (low/moderate/high) # of Days per Week Duration (minutes) Does anything limit you from being physically active? Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high) Work Family Social Financial Health Other What helps you unwind? On average, how many hours of sleep do you get? Weekdays Weekends Do you smoke (please circle)? Never In the past Currently How long? Alcohol use: Never In the past Currently Type/amount/frequency Drug use: Never In the past Currently Prefer not to discuss Type/frequency Weight History Would you like to weight today (please circle)? Yes No Height Weight Desired body weight Highest adult weight When? Weight 1 year ago Have you had any recent changes in your weight that you are concerned about (please circle)? Yes No If yes, please explain: 5
6 Diet History: If I could change three things about my health and nutritional habits, they would be: In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following: To improve your health, how ready/willing are you to: Significantly modify your diet Take nutritional supplements each day Keep a record of everything you eat each day Modify your lifestyle (ex: work demands, sleep habits, physical activity) Practice relaxation techniques Engage in regular exercise/physical activity Have periodic lab tests to assess your progress Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious or other)? Yes No If so, please describe Please list any food allergies, sensitivities or intolerances Who prepares the majority of your meals? Who shops for food? Where do you shop for food? What percent of the foods you eat are whole % organic % convenience % If you do, how much time do you spend cooking/preparing meals each day? Please indicate the materials you use for cooking and food storage (please circle): Plastic Glass Aluminum Styrofoam Stainless Steel Cast-iron Teflon/non-stick Ceramic Do you find cooking difficult? Yes No Please describe 6
7 Which meals do you eat regularly, circle all of the following that apply: Breakfast Lunch Dinner/Supper Snacks (time ) The nutrition/eating habits that are most challenging for me: The nutrition/eating habits that I am most pleased with: Food cravings: Food dislikes: Eating Style: Based on how you eat on a regular basis, please circle all of the following that apply: Fast eater Family member(s) have different tastes Erratic eater Love to eat Emotional eater (stressed, bored, sat, etc.) Eat too much Late night-eater Eat because I have to Time constraints Negative relationship with food Dislike healthy food Struggle with eating issues Travel frequently Confused about food/nutrition Do not plan meals/menu Frequently eat fast food Rely on convenience items Poor snack choices The food/nutrition questions that I would like to ask are: 7
8 Other 5 Whys for Exercise: This is an exercise we use to help you discover why you truly want to be healthier. Why have you decided to seek out a fitness/nutrition professional? Why is that important to you? Why is that important to you? Why is that important to you? Why is that important to you? List any injuries/hospitalizations in the last 5 years: 24-Hour Appointment Cancellation Required Wilmington Performance Lab has a 24-hour cancellation/rescheduling policy. If you miss your appointment, cancel, or change your appointment with less that 24 hours notice, you will be charged for the visit in full. This policy includes personal training and nutritional counseling sessions. Thank you for understanding and your cooperation. I have seen and read the Cancelation Policy below and understand it completely. Please sign: Date: I have seen and read the HIPPA from and understand it completely. (This will be shown when you come in.) Please sign: Date: I have seen and read the WPL Guidelines from and understand it completely. (This will be shown when you come in.) Please sign: Date: 8
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