PATIENT INFORMATION FORM



These forms can be filled out by typing directly into the shaded data fields, or they can be printed out and filled-in by hand. If typing, be sure to save this file on your computer. When completed you can send the file as an attachment via your e-mail program to “responses@”, mail the forms to our office address, or fax them to (732) 469-9777. Thank you.

PATIENT INFORMATION FORM

NAME:      SOCIAL SECURITY #:      

HOME STREET ADDRESS:      

CITY:       STATE:       ZIP CODE:      

HOME PHONE:       WORK PHONE:      

OCCUPATION:      

EMPLOYED BY:      

EMPLOYERS ADDRESS:      

MARITAL STATUS (check appropriate box): Single Married Divorced Widow/Widower

EDUCATIONAL LEVEL:      

HOW DID YOU FIND OUT ABOUT OUR MEDICAL PRACTICE?      

WHO IS RESPONSIBLE FOR PAYMENT FOR SERVICES RENDERED?      

| |

|PLEASE READ THE FINANCIAL POLICY ON THE NEXT |

|PAGE AND THEN SIGN THE STATEMENT BELOW |

I understand and agree that I am responsible for immediate payment of fees for medical services rendered to me by Dr. Condren. I have read and understand the financial policy outlined on the following page of this form.

      DATE:      

Signature (Parent, for minor)

DO YOU WANT OUR OFFICE TO SUBMIT INSURANCE CLAIMS FOR MEDICAL SERVICES RENDERED?

YES NO

If yes, make sure that you complete the insurance verification form, unless you have Medicare coverage

FINANCIAL POLICY

PAYMENT FOR SERVICES IS DUE AT THE TIME SERVICES ARE RENDERED.

For your convenience, our office accepts debit cards and Visa/MasterCard.

Returned checks are subject to an additional $20 fee. Charges may also be made for appointments canceled without advance notice.

The payment arrangements and fees for all of the laboratory tests done in the office are determined by the laboratories. Due to current New Jersey State law, Dr. Condren can not have a financial relationship with any laboratory.

If you have any questions or concerns about the above information, or any uncertainty regarding potential health insurance coverage for our services, please don't hesitate to call and discuss them with us. We are here to help you.

FEE SCHEDULE

The fees written below are the full charges for each procedure listed.

New patient medical evaluation: $225

• includes history taking, physical examination, and laboratory testing recommendations

Regular medical office visit: $110

Extended medical office visit (35-60 minutes): $150-$200

Phlebotomy (blood drawing): $25

ELISA/ACT food allergy test: $360 (must be paid in full when blood sample drawn)

We recommend this test for anybody with medical diseases that are promoted by having a “leaky gut”, or to anyone who is interested in having food allergy testing. Examples of medical conditions for which this test is recommended include: environmental allergies, asthma, eczema, psoriasis, "irritable" and inflammatory bowel disease, and auto-immune diseases (such as rheumatoid arthritis and multiple sclerosis).

Quicksilver Lab Mercury test: $220 done through our office (normal price $350)

PLEASE LIST YOUR MAIN HEALTH CONCERNS:

     

Have you consulted other physicians for any of these concerns? Yes No

If yes, please check the boxes of tests that already have been done to diagnose your problems.

Write in the names & specialties of the doctors that you have seen in the blank form field below the boxes.

TESTS DONE:

MRI scan Endoscopy Ultrasound

CT scan Sigmoidoscopy or colonoscopy X-ray test

EKG Skin allergy testing Biopsies

OTHER tests: please list here:      

     

Please check the following services that are of particular interest to you:

Dietary analysis and recommendations Candida (yeast) testing and treatment

Nutritional supplement recommendations Relaxation training

Food allergy testing Heavy metal testing and treatment

Hormone level testing and treatment Exercise recommendations

The BodyTalk System™ therapy OTHER:      

MEDICAL INFORMATION FORM

Name:      

Date of Birth:       Age:      

Last complete physical exam was done in what year?      

MEDICATIONS: List all prescription and over-the-counter medications you take WITH THE DOSES.

     

MEDICAL ILLNESSES: Check the first column if you have or had any of the following.

Check the second column if a close blood relative has (or had).

Self Relative Self Relative

| |High cholesterol | |Stroke |

| |Heart disease | |Cancer |

| |High blood pressure | |Liver disease, hepatitis, jaundice |

| |Diabetes | |Gallbladder disease |

| |Eczema or hives | |Pneumonia |

| |Psoriasis | |Infectious mononucleosis |

| |Asthma | |Lyme's disease |

| |Stomach problems or ulcer | |Kidney disease |

| |Irritable bowel disease | |Glaucoma, cataracts |

| |Fibrocystic breast disease | |Broken bones, fractures |

| |Thyroid disease, goiter | |Herniated vertebral disk |

| |Uterine fibroids | |Rheumatic fever |

| |Endometriosis | |Epilepsy, seizures |

| |Prostate Disease | |Phlebitis |

| |Arthritis | |Drug abuse |

| |Anemia | |Alcoholism |

ALLERGIES: List anything you are allergic to and what your reaction is to it.

Check here if there are allergy problems in your blood relatives.

     

OPERATIONS AND HOSPITALIZATIONS: Please list below all operations plus reasons for being

admitted to a hospital, and the year they occurred. Do not include normal pregnancies. If none, check here .

Year Operation or illness

|      |      |

|      |      |

|      |      |

|      |      |

|      |      |

FAMILY HISTORY: For each member of your family indicate their present state of health.

(Health)

|List names below |Good |Fair |Poor |Dead |Medical problems |

|Father:       | | | | |       |

|Mother:       | | | | |       |

|Brothers/Sisters:       | | | | |       |

|       | | | | |       |

|       | | | | |       |

|       | | | | |       |

|       | | | | |       |

|Spouse:       | | | | |       |

|Child:       | | | | |       |

|Child:       | | | | |       |

|Child:       | | | | |       |

|Child:       | | | | |       |

SUPPLEMENTS:

Please list all nutritional supplements (such as vitamins, minerals, herbs, and other preparations) that you currently take on a daily basis and the amounts of each that you take.

     

____________________________________________________________________________________________FOR OFFICE USE ONLY

EX: BFB: D&N:

Name:      

REVIEW OF SYSTEMS FORM

If you are experiencing (especially within the past year) any of the following symptoms or medical problems, rate its frequency, intensity, and duration as defined below. Leave blank if you do not experience it.

Frequency (FREQ) Scale:

1 = Occurs about every 2-3 months or less

2 = Occurs about once or twice a month

3 = Occurs about 1-2 times a week

4 = Occurs about 3-5 times a week

5 = Occurs every day or is always present

Intensity (INT) Scale: Rate on a numerical scale from 1 = mild to 5 = severe.

How Long: Enter approximately how long it has been present in your lifetime in months (M) or years (Y).

FREQ INT HOW LONG FREQ INT HOW LONG

|GENERAL: Tired, Fatigue |      |      |      |LUNGS: Wheezing |      |      |      |

| Trouble falling asleep |      |      |      | Short of breath |      |      |      |

| Trouble staying asleep |      |      |      | Dry Cough |      |      |      |

| Family-related stress |      |      |      | Cough up mucus |      |      |      |

| Work-related stress |      |      |      | Cough up blood |      |      |      |

| Difficulty concentrating |      |      |      |CIRCULATION: Chest pain |      |      |      |

| Mental fogginess; poor clarity |      |      |      | Chest tightness or pressure |      |      |      |

| Difficulty with memory |      |      |      | Racing or irregular heartbeat |      |      |      |

| Cravings for sugary foods |      |      |      | Leg cramps |      |      |      |

| Cravings for salty foods |      |      |      | Ankles or feet swell |      |      |      |

| Eyes sensitive to light |      |      |      | Fluid retention |      |      |      |

| Depression |      |      |      | Cold hands and/or feet |      |      |      |

| Trouble relaxing |      |      |      | Varicose veins |      |      |      |

| Tend to worry |      |      |      |DIGESTIVE: Nausea |      |      |      |

| Feel irritable or angry |      |      |      | Vomiting |      |      |      |

| Tend to feel cold easily |      |      |      | Heartburn |      |      |      |

| Unusual hunger or thirst |      |      |      | Upper abdominal pain |      |      |      |

| Loss of appetite |      |      |      | Lower abdominal pain |      |      |      |

|HEAD: Headaches |      |      |      | Diarrhea (loose or watery) |      |      |      |

| Sneezing |      |      |      | Constipation |      |      |      |

| Sinus congestion |      |      |      | Tan, beige, or yellow BM's |      |      |      |

| Nasal congestion |      |      |      | Blood in BM's or rectum |      |      |      |

| Post-Nasal Drip |      |      |      | Excess gas |      |      |      |

| Ear ache |      |      |      | Abdominal bloating |      |      |      |

| Eyes water or itch |      |      |      | Hemorrhoids |      |      |      |

| Decreased taste sense |      |      |      | Black stools |      |      |      |

| Bad or bitter taste in mouth |      |      |      |URINARY: Painful urination |      |      |      |

| Bad breath |      |      |      | Hard to stop or start urine |      |      |      |

| Coat on tongue |      |      |      | Brown or bloody urine |      |      |      |

| Mucus in throat |      |      |      | | | | |

| Sore tongue |      |      |      |MALES: Prostate pains |      |      |      |

| Sore or swollen gums |      |      |      | Weak flow of urine |      |      |      |

| Nose bleeds |      |      |      | Discharge from penis |      |      |      |

| Dark circles under eyes |      |      |      | | | | |

FREQ INT HOW LONG

|FEMALES ONLY: Heavy menses |      |      |      |

| Vaginal discharge or burning |      |      |      |

| Cramps with menses |      |      |      |

| Premenstrual Symptoms |      |      |      |

|SKIN: Dry in cold weather |      |      |      |

| Acne |      |      |      |

| Bruises easily |      |      |      |

| Itchy |      |      |      |

|MUSCLES/BONES: Back pain |      |      |      |

| Sciatic pain down legs |      |      |      |

| Joint swelling |      |      |      |

| Joint pain/aching |      |      |      |

| Muscles ache |      |      |      |

| Cramps |      |      |      |

| Muscle weakness |      |      |      |

|NEURO: Dizziness |      |      |      |

| Fainting |      |      |      |

| Convulsion/seizures |      |      |      |

Please record the average number of how many times per year you have the following problems:

TIMES/YEAR

|Migraine headaches |      |

|Head colds |      |

|Viral "flu" infections |      |

|Sinus infections |      |

|Sore throats |      |

|Bronchitis |      |

|Urinary tract infections |      |

Please place a check in the box preceding each statement if it applies to you:

Smoke cigarettes OR Quit smoking about       years ago

Recent weight gain or loss

Consume more than 2-3 alcoholic drinks a week

Get symptoms of being sick from consuming small or moderate amounts of alcohol

Consume more than 1 cup of coffee a day

Overly sensitive to the effects of caffeine on your body

Occasionally engage in recreational drug usage

Frequently take antibiotics for more than 2 weeks a year

Have taken antibiotics continuously for more than 1 month in the past

Have had multiple episodes of athlete's foot rash

Get symptoms of being sick from exposure to cleaning chemicals, perfumes, paint or gas fumes, or pollution

FOR FEMALES ONLY:

In menopause (have had no periods) since       (year)

Have had more than 2 vaginal yeast infections in my life

Take over-the-counter or prescription drugs for menstrual cramps

May skip a month (or more) in menstrual cycle

Have the following premenstrual symptoms (please check) for       days before my periods:

Breast tenderness or pain Fluid retention or weight gain

Easily irritated or angered; moody Depression

Cramps Headaches

Abdominal bloating Constipation or diarrhea

NUTRITIONAL QUESTIONAIRE

Do you believe that what you eat may strongly affect your health and/or how you feel?

yes no

Our focus of treatment is on dietary interventions to promote the body’s ability to heal itself. Are you willing to make major changes in your diet?

yes no

Have you already made healthy changes to your diet? yes no

If yes, please describe the changes:

     

Please estimate the number of servings per day or week that you drink or eat the following foods:

| | |NUMBER OF SERVINGS |

|FOOD |SERVING SIZE |PER DAY OR PER WEEK |

|Water |8 oz. glasses |      |      |

|Cooked Vegetables |½ cup |      |      |

|Salad |1 cup |      |      |

|Fruit Juices |8 oz. |      |      |

|Fresh Fruit |One piece or ½ cup |      |      |

|Bread |One piece of bread |      |      |

|Crackers |4 oz. |      |      |

|Processed Breakfast Cereals |1 cup |      |      |

|Pasta |1 cup |      |      |

|Whole Grains (i.e., oats, rice) |1 cup cooked |      |      |

|Dried Beans (legumes) |½ cup cooked |      |      |

|Eggs |1 egg |      |      |

|Fish |3 oz. |      |      |

|Poultry |3 oz. |      |      |

|Beef |3 oz. |      |      |

|Pork |3 oz. |      |      |

|Cheese |2 oz. |      |      |

|Yogurt |½ cup |      |      |

|Milk |8 oz. glasses |      |      |

|Coffee, Regular |8 oz. cups |      |      |

|Coffee, Decaf |8 oz. cups |      |      |

|Regular Tea |8 oz. cups |      |      |

|Herbal Teas |8 oz. cups |      |      |

|Soda/Soft Drinks |12 oz. |      |      |

|Candy |1 bar |      |      |

|Cake |One 2” piece |      |      |

|Ice Cream/Frozen Yogurt |½ cup |      |      |

|Cookies |One 2” cookie |      |      |

| |8 oz. glass of wine |      |      |

|Alcohol | | | |

| |12 oz. beer |      |      |

| |1 oz. hard liquor |      |      |

How many times a week do you eat deep-fried foods, such as potato chips, French fries,

or fried chicken?       times a week

Please rate the quality of your diet: Excellent       Good       Fair       Poor      

How many times do you eat during the day (meals and snacks)?      

What percentage of your meals are prepared at home?      %

What percentage of your meals are eaten out?      %

Please rate the level of your cooking skills: Excellent       Good       Fair       Poor      

Please rate on a scale of 1-10 how much you enjoy cooking:

(10 = very much; 1 = hate it)      

Do you have to watch what you eat to avoid gaining weight? yes no

Do you have to watch what you eat to avoid losing weight? yes no

Do any foods seem to irritate you in any way? yes no

Please name the food and describe the problem.

     

What foods do you have a craving for?

     

What foods do you dislike?

     

Do you feel your diet is excessive in some respect? yes no

Please describe:

     

Do you feel your diet is deficient in some respect? yes no

Please describe:

     

Please feel free to write in any further information that you feel is important:

     

INSURANCE VERIFICATION FORM

Complete this form if you want the office to submit claims to your insurance company.

This form does not need to be completed if you wish us to submit claims to Medicare.

Call your insurance company to complete this form (unless you already know all of the answers).

Name of insurance company:      

Name of person who gave you the information:      

Ask the following questions:

1. Does my policy provide benefits for ANY MEDICAL DOCTOR that I choose to see? YES NO

2. Does my policy provide benefits for ANY LABORATORY that I choose to use? YES NO

IF NO, what laboratory must I use?      

3. Does my policy cover outpatient medical office visits and diagnostic tests?

Are there any limits to my coverage? YES NO

Please describe any coverage limits: (Be as specific as possible)

     

4. What is the address of the office where the claims are to be sent?

     

5. Individual policy? YES NO OR Group Policy: YES NO

Identification number:       Group Policy number:      

Name policy is under:      

Employee's Company Name:      

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