Www.gutwhisperer.com
New Patient Information
Name:__________________________________________________Date of Visit:______________________________________Age:________
Current Medications:___________________________________________________________________________________________________
Allergies (food and medications):__________________________________________________________________________________________
Reason for visit:_______________________________________________________________________________________________________
Past Medical History: List any major illnesses, hospitalizations or diagnosis: (i.e., high blood pressure, diabetes, depression, reflux, arthritis…) please include dates _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Past Surgical History: Please list any surgeries and dates: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Social History Occupation:______________________________________________________Number of Children_________________
Do you smoke?_____How much?___________ Have you ever smoked?______ For how long?______ When did you qui?t______________
Do you drink alcohol? ________How much?_______________Have you ever used illegal drugs? _________________________________________
Have you traveled out of the state or country ?________Where?___________________________________________________________________
Have you used antibiotics in the last 3 months?__________________________Do you have any pets?______What type?______________________
Family History: What diseases do you have in your family? (high blood pressure, diabetes, heart attack, colon cancer or other diseases)______________________________________________________________________________________________________________
Do you have: (you may circle any of these symptoms or add other you have had)
General: fevers, sweats, chills, weight loss or gain, appetite or sleep changes?
Heart: chest pain, difficulty breathing, swelling, dizzy, rapid heart rate?
Lungs: cough, painful breathing, wheezing, pneumonia, asthma or COPD?
Urinary: painful urination, frequency, night urination, blood or other discharge in your urine?
Muscles/bones: fractures, injuries, pain or stiffness?
Skin: itching, rash, swelling, changes in breast tissue?
Nerves: head injury, headaches, dizzy, fainting, seizures, stroke, trembling?
Psyc: depression, anxiety, difficulty coping or sleeping, forgetfulness?
Metabolism: dry, sweaty or changes in skin color, voice changes, excess hair growth, heat or cold intolerance, tremor?
Blood: anemia, bruising easily, excess bleeding, pale, blood transfusions, swollen lymph nodes?
Allery: hayfever, frequent sinus infections, eczema or itchy skin?
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