Adult New Patient Information Form

New Patient Information Form		carlstonmd.com

Adult New Patient Information Form


Name________________________________________________ Birthdate__________________
Mailing Address______________________________City ____________________ Zip ________
UPS Address________________________________ City ____________________ Zip ________
Home Phone_________________ Work Phone ________________ Marital Status ____________
Fax______________________________ e-mail address _________________________________
Occupation ___________________________ Who referred you ?__________________________
Prior Homeopathic treatment ?_____ By Whom___________________Date Last Seen _________
IN THE EVENT OF EMERGENCY PLEASE NOTIFY:
Name ___________________________________ Phone _________________________________
MEMBERS OF YOUR HOUSEHOLD

NAME

AGE

RELATIONSHIP

ALLERGIES (please list all known or suspected drug sensitivities as well as environmental allergies)

__________________________________________________________________________________________

MEDICATIONS, VITAMINS and SUPPLEMENTS (include non-prescription and herbs)
NAME	DOSAGE	FREQUENCY

__________________________________________________________________________________________

HEALTH HABITS

How many times each week do you exercise for 20 minutes or more ?_________

How do you exercise ? ______________________________________________________________

Do you smoke cigarettes ?______ If so, how many each day ?______ At what age did you start ? _____

Do you drink alcohol ?____ How much each week ?_______

Are you concerned about your use of alcohol? _____

Do you use other recreational drugs ?_____ Are you concerned about your use of those drugs ?______

Do you drink coffee ?______ How much ?__________Do you eat a well balanced breakfast ?_________

Do you wear seatbelts every time you are in an automobile ?_______ Are you a careful driver ? _________

Do you set aside enough time for adequate relaxation ?________ How do you relax ? ________________

__________________________________________________________________________________________

ARE YOU EXPOSED TO ANY TOXIC SUBSTANCES ?

(Please provide details regarding those exposures that concern you)

__________________________________________________________________________________________

WHAT HEALTH PROBLEMS ARE YOU PARTICULARLY CONCERNED ABOUT

__________________________________________________________________________________________

WHAT RECENT LOSSES OR UNUSUAL STRESSES HAVE YOU EXPERIENCED ?

__________________________________________________________________________________________

PLEASE CIRCLE ANY DISEASES THAT YOU OR YOUR FAMILY HAVE SUFFERED

Alcohol/Drug Problems	Allergies	Alzheimers Disease	Anemia	Arthritis/Gout	Asthma
Bleeding Problems	Cancer	Convulsions/Epilepsy	Diabetes	Eczema	Emphysema
Heart Trouble	Hepatitis	High Blood Pressure	Kidney or Bladder Problems
Menstrual Problems	Mental Illness	Migraines	Pneumonia	Polio	Rheumatic Fever
Stomach /Intestinal Disease	Stroke	Thyroid Problems	Tuberculosis	Ulcers
Venereal Disease	Weight Problems

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