Global Wellness PATIENT INFORMATION
Last Name Street Address Home Phone Best place and time to contact you: SS # Cell Phone First Name City State Work Phone Middle Initial Zip
Can we leave a message at home: Y or N Can we leave a message at work: Y or N Date of Birth/Age Male or Female Email Name and phone number of person Referring you? Relationship to Emergency Contact Marital Status: M S D
Parent/Guardian Name and Address (for minor patients) Primary Care Physician (name and phone number) Referring? Yes/no Emergency Contact Emergency Contact’s Phone #
Symptoms of Concern Children are usually referred because they are having behavior problems at home or at school or are underachieving academically. The primary area of difficulty - inconsistent control over attention and impulses - often results in failure experiences academically, socially, and within the family. In the space below briefly answer the following questions: What problems are being experienced?
How long has this condition existed? What have you noticed behaviorally? Lack of Attention: Easily distracted: Impulsive: Hyperactive:
Learning disabilities can make learning and school work very difficult for a child. As a result, children experiencing learning difficulties often begin to feel demoralized, and problems with self-esteem frequently emerge. Have you noticed this any problems in this area?
Has the school noticed any problems in this area?
Patient/Guardian Signature
Date
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Symptoms and Ailments Questionnaire
Please check the appropriate box for each question. Symptoms Frequently
Cold hands, feet, low body temperature Fatigue/ tiredness Inability to lose weight despite dieting Poor memory Poor concentration Constipation Diarrhea Hair loss Depression Anxiety/ nervousness Irregular heart beats Trouble sleeping Muscle weakness Muscle aches Joint pain Headaches Early morning stiffness Easy fatigue from exercising Sleepiness in the afternoon Excessive thirst Sugar cravings Dizzy/ lightheaded Shaky or irritable when hungry Bloating/ gas Belching Rectal itching/ nasal itching Vaginal yeast infections Toe fungus, jock itch, or athlete’s foot High sensitivity to smells Chronic or long term hives Excessive body or foot odor Bad breath Sinus problems Sore throat Loss of voice / hoarseness Burning or tearing of the eyes Easy bruising Slow wound healing What did you have for? Breakfast (today): _____________________________________________ Lunch (yesterday or today):_________________________________________________ Dinner (yesterday):________________________________________________________ Snacks (past 24 hours):_____________________________________________________ Beverages (past 24 hours):__________________________________________________
Occasionally
Rarely
Never
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