A.-} Lifetime ¥WELLNESS

NEW PATIENT INTAKE FORM Name:

Age:

Sex: M

F

DOB: _ .... ! -!-I_

SSN:

Marital Status: S M W D

Heigbt: ___

Addr_:

--------_._--­

CitylState: __________

Phone#:

Weight: _ _ __

Zip: _ __

Email:,_ _ _ _ _ _ _ _ _ _ _ __

Occupation: _______

Please circle for thefollowing question.: Raee: White I Black I Hispanic! American Indian I Alaska Native I Asian I African American I Native Hawaiian lother Ethnicity: Hispanic I Latino I Not Hispanic I Not Latino I Other

Language: English! Spanish I Italian I French I Gennan! Chinese! Arabic! Other

Emergency Contact: _ _ _ _ _ _ _

Relalion:

PCP: _ _ _ _ _ _ _ _ _ _ _ _ _

Pllone:

Phone #

_ _ _ .__

~

Address:

Referring MD: _ _ _ _.._ _ _ _ Phone: Address:

Pharmacy Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone: _ _ _ _ _ _ __

_______________________________________________

PharmacyAddre~:

How did you hear aoout our office? Doctor iFriend/InternetJOther: __________________________

Primary Insuraoce

INSURANCE INFORMATION Secondary Insurance

Company: Card Holder:

."N",a",m",e,,-:_ _ _ _ _ _ _ _ _ _ _ __

Name:

Card Holder:

"'DO:=B"':_-"'/.....:.1_"'S"'S"'N.... : _ _ _ _ _ __

DOBi

I

I

SSN:

Policy # Group# MEDICAL CONSENT-PLEASE SIGN I AUTIIORIZE AND AGREE TO THE DIAGNOSTIC TESTING AND TREATMENT BY Tllll STAa' OF LIFETIME WELLNESS. ITS ASSOCIATES AND SUBSIDIARIES. I HEREBY Al.JTlI0RIZE LIFETIME WELLNESS, ITS ASSOCIATES AND SUBSIDlARlES TO TIm FILING OF INSURANCE AND RELEASE OF rNFORMATION NECESSARY TO PROCESS MY CLAIM. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UFETIME WELLNESS, ITS ASSOCIATES AND SUBSIDIARlBS FOR SERVICES RENDERED. 1 UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR ALL CO~PAYS. DEDUCTIBLES A.t~D CHARGES NOT PAID BY nrn INSlJRANCE COMPANY.

===-------------------------,,:~--

SIGNATL'"RE

DATE

..

-.~-.-.

187 MilIbwn Avenue, Suite 103, Millburn, NJ 07041 Tel: 973-544-1196 Fax: 973-544-1197 www.Lifetime-Wellness,coffi

A-1A Lifetime

V'WELLNESS

In order for us to provide tbe best care, it is important for you to fill out this form completely and accurately. Please fiJI out every Item. Please mark uN/A" in any categories that do not apply to you. How would you rate your current bealth? DExceUent DGood DAverage D Fair DPoor What are your medical goals?_. -~.-~.~.---

Do you experience any occupational stress factors (physical, psychological, chemical)?:

Do you follow a regular exercise program? Yes

No

Please describe:

Please describe your average daily diet:

How well do you feel you manage your stress? D Excellent

OGood

DAverage DFair

0

Poor

Please list any history of trauma you have experienced (Le. car accidents, head injuries, broken bones, etc.)

Are you allergic to any foods?

~_

If yes, please list the food(s) and describe the reaction: .._ _ _ _ _ _ __

Are you allergic to any medications? 0 No MEDICATION ALLERGIES: Please List Name Reaction

0

Yes If yes, please list below. MEDICAL mSTORY: Please List All Medical Diagnoses

CURRENT MEDICATIONS: (please include vitamins, fish oil and aspirin, etc.) Name and dosage Doses per day Prescribing Physician

Store purchased at (if supplement)

FAMILY MEDICAL IDSTORY:

Age Mother: Father: Siblings: _ _

Diseases

If deceased, cause of death

187 Millburn Avenue, Suite 103, Millburn, NJ 07041 Tel: 973-544-1196 Fax: 973-544-1197 www.Lifetime-Wellness.com

.. -.. Lifetime ~WELLNESS SURGICAL HISTORY: Please list all surgeries you have had

Date

------------.---­ Have you ever had any problems with anesthesia? 0 No 0 Yes If yes, please list what sort of problems: _ _ ~_._. _ __

SOCIAL mSTORY: Please mark all that apply to you No How much? ________ Do you drink coffee, tea, soda? Yes

Wioe 0 Beer 0

Do you drink alcohol? Yes_ No

How often? ._ _ _ _ _~

Liquor 0

Do you smoke?

How many packs per day?

For how long? _ _ _ _ _ __

Yes_ No _

Any history of smoking? Yes_ No _

How many years? ___

Do you use illicit drugs? Yes_ No

How often?

~--~--

How long ago did you quit? ~ _ _

Have you had or do you have an addiction problem? Yes _ _ No ..___

REVIEW OF SYSTEMS Please check all that apply to you: EYES. EARS. NOSE. THROAT (check all that apply): Eyes:

0

Pain

0

Redness

0

Dryness

0

Swelling

0

Blurred vision

0

Floaters

0

Sensitivity to light

o Pressure in eyes Ears: Nose:

0 0

0

Tinnitus (ringing in the ears)

0

Frequent nosebleeds

Hearing loss

Stuffy nose

0

Sinus Infections

Throat: OFrequent Sore throatIHoarseness Cough: Oili~:

0

Chronic, recurrent

0

Recent, sudden onset

0

Coughiog blood

0

Dry

0

Cough up mucous

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

CARDIOPULMONARY (cheek all that apply):

o Chest Pain at Rest 0 Chest Pain with Exertion 0 Chest pain radiating into left arm or shoulder 0 Wheezing o PalpitationsiRapid or Irregular Heartbeat OHigh blood pressure []Low blood pressure 0 Lelllcalf pain while walking o Fluid retention (e.g. swollen ankles, legs, etc) OShortness of breath METABOLICIENDOCRINE (check all that apply):

o Hypersensitivity to coldlcold hands and feet

0

0

Difficulty breathing while laying flat

Swollen (bulging) eyes OThinning of eyebrows

OExcessive thirst OExcessive urination OExcessive hunger

OCrave salty foods OCrave sweet foods ONeed to drink caffeine to get going

o Experience fatigue, irritability or cravings after eating sweets

0

0

Hot flasheslExcessive sweating

Irritable or tired/weak when missing a meal

SKIN & HAIR (check all that apply):

o Dry skin 0 Skin rashes 0 Itching 0 Acne 0 o Drylhrittle andlor flaky hair OExccssive sweating

Eczema

0

mves

0

Hair los.

0

Premature graying

Oilier: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

187 Millburn Avenue, Suite 103, Millburn, NJ 01041 Tel: 973-544-II96 Fax: 973-544-1191 www.Lifetime-Wellness.com

Lifetime

. .I).... VWELLNESS

NEUROLOGICAL (check all that apply):

o Muscle weakness 0 Tingling or numbness 0 Tremors 0 Memory loss or inabiliry to concentrate o Loss of smell or taste 0 History of seizure or convulsions 0 Carpal tunnel syndrome o Vertigo 0 Di?.ziness, please describe .. Nape of neck, back of head

0 0

Forehead

0

0

Dull, diffuse

HEADACHES Onset: ORecent, acute Location:

0

Type of pain:

Sharp, stabbing, intense

0

Recurrent, chronic

0

0 Starts gradually 0 Top of head 0 Whole head

Starts suddenly

Temples, sides of head Other:

-----~------------~----

Any associated symptoms? (i,e, vomiting, nausea, disturbance of vision, etc,) ~.._ _ _.. _ _ _ _ _ _ _ _ _ _ _ _ _ __

Is there anything you do that eases the pain? .

BODYACHES & PAINS OR NUMBNESS Location:

0

o

Whole body 0 Muscles & tendollll 0 loints 0 Backache 0 Chest 0 Upper abdomen Lower abdomen 0 Flanks, ribs 0 Other_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

When did the pain begin or what brings it on? . _ _ _ _ __

GASTROINTESTINAL (check alltha! apply):

0

Food:

No appetite

0

Good appetite

0

I have or have often had (cbeck all thaI apply):

Feel better after eating

0

Belcbiog

0

0

Feel worse or tired after eating

0

Nausea

Vomiting

0

Vomiting of blood OUicers

o Bloating/Flatulence 0 Aeid regurgitation 0 Heartburn 0 Hernia 0 Indigestion 0 Unintentional weight loss o Abdominal pain ODifficulty or pain .wallowing OOther _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ BOWELS & URINATION: Do you have or have a tendeney towards:

0

Constipation

0

Diarrhea or loose stools

How often do you have a bowel movement? _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Watery 0 Dry 0 Undigested food 0 Blood 0 Pus or mucus o Painful defecation 0 Borborygmus (gurgling in abdomen) 0 Burning sensation 0 Flatulence Urine eolor: 0 Pale yellow 0 Dark yellow/orange 0 Blood in urine 0 Cloody or partieles in urine I have or have had (cheek all that apply): 0 Trouble starting stream 0 Frequent urination 0 Incontinence o Pain 0 Trouble holding urine 0 Burning 0 Dribbling wben sneezing 0 Urinary traet infections o Kidney stones OHemorrhoids 0

Stools:

0

Formed

0

Loose

SLEEP & EMOTIONS I normally sleep _ _~ bours per night

I have diffieulties with:

o Excessive fatigue despite adequate sleep 0 Staying asleep 0 Sleep Apnea/Snoring 0 Night sweats 0 Insomnia o Bad temper, irritability 0 Nervousness 0 Anxiety or phobias 0 Poor memory 0 Difficulty concentrating ~ber:

_____________________________________________________________

WOMEN'S HEALTH Date of last menstrual period: =---------~---c_-=If you are still menstruating, please eheck all that apply: ORegular cycle, period every ~._~ days

o Period always early

0

Period always late

0

Number of days of flow: _ _ Discomfort/pain: PMS symptoms:

0 0

Heavy flow

Before period

0

0 0

0

No

Light flow

Doring period

0

Irregular menstruation

Spotting between periods

0

0

Clots

After period

Breast leoderness. swelling Olrritability

Have you bad a hysterectomy?

0

0

0

Breast or nipple tenderness/swelling

Bloating, edema

Other: _ _ _ _ _ _ _ _ _ _ __

Yes, please indicate date and reason: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

187 Millburn Avenue, Suite 103, Millburn, NJ 07041 Tel: 973-544~ 1196 Fax: 973-544-1 197 www.Lifetime-WeDness,com

... ·~Lifetime ¥'WELLNE5S h-1enooousal symptoms: itcbinglhurning

0

Hot flashes

0

Night sweats

0

Inereased anxiety/irritability

0

Frequent urination

0

Vaginal

PIe

!ndividuals Involved io Your Care or Payment for your Care We may release medical information aooutyou to Ii friend or family

member who is involved in your medical can. We may aJS(I give infunrurtion to someone who belps pay for your c~ We may

also tell your family ur frimd!!l your a)ndition, In additiOb, we may dbclost medical information about you to an entity

usisdog in a diwltr relief clTon so that your family can be notified about your eOQdidon, datu and location.

:;;.

RtStanh. Undtr certain ciramstances, we may we aJtd disdose medJ('.8.1 information about your for rtsean:b purposes. For

example, a rt:l!It8nb projt(t may involve comparing the healtb and ret