Mantality New Patient Paperwork

Mantality New Patient Paperwork

St. Louis, MO
Welcome to Mantality Health. Through our desire to provide you with the most focused and personalized experience, we would like to understand the primary reason that has brought you to the center today. Please take a moment to identify which of the following you are hoping to achieve through your care:

Please assign a numerical value from 1-6 to each goal in order of importance:

	Put Numerical Value
Weight Gain/Loss
Fatigue
Results in the Gym
Mental Acuity (Sharpness)
Sexual Function/Performance
Other (Please Specify)

Please list your overall goals during treatment:

Describe a time when you were performing at your best:
PATIENT INFORMATION:
How did you hear about us? Referral Internet Radio: blank
General Information:
Date

DayMonthYear
Date
Birth Date:

DayMonthYear
Date
Age
Name

First NameMiddle NameLast Name
Email
example@example.com
Marital Status:

SingleMarriedDivorced
General Information (Continued):
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Cell Phone:
May we send you a text message reminder regarding appointments?

YesNo
Would you like to receive emails from Mantality?

YesNo
Place of Employment:
Phone:
Employer Address:

Street Address

Street Address Line 2

CityState

Zip Code
Primary Doctor:
Phone:
POLICY HOLDER INFORMATION (if different than yourself):
Name

First NameMiddle NameLast Name
Relationship:
Date of Birth:

MonthDayYear
Date
Phone:
Policy ID #:
Group #:
Please upload a picture of the front and back of your insurance card

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EMERGENCY CONTACT
Name

First NameMiddle NameLast Name
Relationship:
Home Phone:
Cell Phone:

PATIENT HISTORY

	Yes	No
Have you had any muscle weakness, fatigue or loss of muscle mass?
Has your interest in sex (libido) declined?
Do you have spontaneous erections (without medication or other aid)?
Has your energy or stamina declined?
Have you lost self-confidence, motivation or initiative?
Has there been any decline in memory or concentration ability?
Have you had any sleep disturbance or problems breathing while asleep?
Do you have mood swings or depression?
Have you noticed any increase in aggressiveness?
Do you have any breast tenderness or enlargement?
Have you lost any hair in the genital or underarm areas?
Has your need to shave decreased?
Have you noticed any significant change in the size of your testicles?
Do you have periodic hot flashes or sweats?
Have you ever had problems achieving a pregnancy?
Are you considering having any (or more) children?

FAMILY HISTORY

	Yes	No
Do you have any blood related family members with breast cancer?
Do you have any blood related family members with prostate cancer?
Do you have any blood related family members with diabetes?
Do you have any blood related family members with cardiovascular disease?

SOCIAL HISTORY

	Yes	No
Do you use tobacco? If yes, how many packs per day:
Do you drink alcoholic beverages? If yes, how much and how often:

PAST HISTORY

	Yes	No
Have you ever had an abnormal PSA test or prostate exam?

	Yes	No
Thyroid Disease.

	Yes	No
Diabetes.

	Yes	No
High Blood Pressure.

	Yes	No
Asthma/Lung Disease.

	Yes	No
Acne, Dry or Oily Skin.

	Yes	No
Venereal Disease.

Do you currently take any medications? If so, list below:

REVIEW OF SYMPTOMS (please check all that apply):
Ears, Nose and Throat:

Hearing LossTrouble SwallowingRinging in EarsNeck Pain/StiffnessAltered Sense of Smell
Lungs:

Nonproductive CoughPain w/ Breathing at RestPain w/ Breathing with ExertionPain wit InspirationShort of Breath w/ ExertionWheezingCoughing up Blood
Cardiovascular System:

Chest Pain/Pressure at RestChest Pain/Pressure with ExertionHeart PalpitationsNormal Tolerance to ExercisePain in Legs when WalkingCold Hands/FeetFaintingLightheadedness
Hematology (Blood):

AnemiaHemochromatosis
Allergic:

Hives
Gastrointestinal System:

Pain with SwallowingVomitingAbdominal PainNausea
Eyes:

HeadacheVisual Changes.Blurry VisionDouble Vision
Genitourinary System:

Pain with UrinationBlood in UrineErectile DysfunctionUrinary FrequencyTrouble Starting StreamUrinary InfrequencyDifficulty Stopping Stream
Neurological System:

HeadacheLoss of Sensation in any Part of BodyWeakness of any ExtremityUncontrolled Muscle MovementsSpeech DisturbanceDizzinessProblems with Walking
Musculoskeleta l System:

Joint Pain (any Joint)Pain in any MusclesMuscle Weakness
General Constitution:

FatigueWeight GainNight SweatsWeight Loss
Integumentary (Skin) System:

Rashes
Psychiatric:

Depressed
Endocrine:

GoiterAppetite ChangeHeat or Cold Intolerance
Comments:
Please upload a picture of the front of your driver's license

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Patient Signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

General Information: