Center for Health and Healing New Patient Medical Forms
Welcome and thank you for choosing Center for Health and Healing. As a new patient to our office, it is extremely important for us to understand your current health concerns as well as your full medical history. It is likely that we are requesting more medical information than you've had to complete for other medical practices, however this additional information allows our Doctor to provide a more complete medical plan for you. The forms herein must be completed by you, or your agent, at least three days prior to your appointment. If not, we reserve the right to reschedule you.
Date of birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What is your occupation?
*
The name of the person completing this form
*
First Name
Last Name
Relationship of this person to the patient
*
Please Select
Self
Spouse
Parent
Daughter/Son
Other
How did you hear about Dr. Rind? If someone referred you to us, please let us know. We'd like to thank them!
*
Please let us know what are your primary reasons for seeking care with us. Please list them in order of greatest concern.
Concern #1: greatest important
*
Concern #2
Concern #3
Concern #4 - least important concern
Your are doing great! Next, let's do a Review of Systems. Please click on any of the symptoms you may be or have been experiencing and also indicate for how long you have had them.
General Symptoms
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Fatigue
Low Grade Fever
Anorexia
Heat Intolerance
Cold Intolerance
Brain Fog
Skin, Hair and Nails
Rows
Current, Recent
Less than 1 month
6-12 months
2-6 months
>1 year
New rashes (if yes, note location)
Bruising (if yes, note location)
Cracked Lips
Bug bite (tick or other, if yes, note location)
Dryness
Excessive perspiration
Hair loss
Hives
Itchiness (if yes, note location)
Lack of perspiration
Pallor
Brittle nails
Peeling nails
Thin nails
Thickened nails
Nail Fungal Infections
Nail Ridges
If you clicked rashes, bruising, bug bite, or itchiness please explain the location and details below.
Head, Eyes, Ears, Nose and Throat
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Light Sensitivity
Eye Redness
Poor Night Vision
Difficulty driving at night
Visual problem
Eye dryness
Headaches
Migraines
Sinusitis
Hearing Loss
Itching Ears
Respiratory Symptoms
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Shortness of breath
Cough
Difficulty breathing
Asthma
Bronchitis
Gastrointestinal
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Constipation
Diarrhea
Irritable bowel
Generalized abdominal pain
Sharp abdominal pain
Poor digestion
Excessive gas
Acid reflux
Cardiovascular Symptoms
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Chest Pain
Leg or ankle swelling
Elevated blood pressure
Palpitations
Cold extremities
Clotting problem
Bleeding problem
Musculoskeletal
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Muscle pain (if yes, note location)
Muscle weakness (if yes, please note location)
Disc problems
Back pain
Short leg
Calf pain
Leg Cramps
Decreased Range of motion
Joint Pain (if yes, note location)
Joint swelling (if yes, note location)
Joint stiffness
Did you say yes to muscle pain, muscle weakness, joint pain or swelling? Tell us more about the location of this/these symptoms here:
Neck
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Neck mass
Neck pain
Neck stiffness
Neurological
Rows
Current, Recent
Less than 1 month
2-6 months
6-12 months
More than one year
Neuropathy/burning/pain (if yes, note location)
Vertigo
Loss of equilibrium
Numbness (if yes, note location)
Pins and needles (if yes, note location)
Tingling (if yes, note location)
Unexplained weakness
Trouble walking
Clumsiness
Balance problems
Speech problems
Memory problems
Headaches
Tremor (if yes, note location)
Incontinence stool
Incontinence urine
Seizures
Did you say yes to numbness, pins and needles, tingling or tremors? If so, tell us about the location of this/these symptoms here:
Psychiatric
Rows
Current, Recent
Less than one month
2-6 months
6 to 12 months
More than one year
Depression
Anxiety
Irritability
Insomnia
Hypersomnia
Inability to concentrate
Mood changes
Suicidal thoughts
* Are you in crisis? National Suicide Prevention Lifeline. 800-273-8255
https://suicidepreventionlifeline.org/
Endocrine
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Excessive thirst
Sexual dysfunction
Libido change
Low blood pressure
Low body temperature
Cold extremities
Low blood sugar
Light sensitivity
Poor stress tolerance
Weight grain
Weight loss
Fatigue easily
Thyroid
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Hyperthyroid
Hypothyroid
Cysts/Nodules
Lower neck swelling
Genitourinary
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Frequent urination
Kidney Disease
Bladder infections
Incontinence
Male Issues
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Impotence
Prostate problems
Female Issues
Rows
Current, Recent
Less than one month
2-6 months
6-12 months
More than one year
Hot flashes
Trouble with cycles
PMS
Non-cycle bleeding
Fibroids
Ovarian cysts
Yeast Infections
Other infections If (yes, please note below)
Did you click on "other infections"? If so, tell us more about that here:
Breast Issues (Men and Women)
Rows
Part of my history
Fibrocystic
Lump or mass
Tenderness (if yes, please note location below)
Nipple discharge
Nipple changes (shifting, retracting)
Insect bite(s)
Did you click on breast tenderness or nipple changes? Tell us more about this here:
Hematology
Rows
Part of my history
Swollen glands (if yes, please note location)
Excessive bleeding
Enlarged lymph nodes (if yes, note location)
Anemia
Bruising (if yes, note location)
Did you click on enlarged lymph nodes or bruising? Tell us more about its location here?
You are making great progress! Now onto Personal & Family Medical History
Specific Medical History Items: It is important for our Doctor to know if you have any history of the following issues. Please check the box next to any of the following included in your past or current medical history and, if applicable, provide the year of diagnosis (or occurrence) and any treatment received.
Immune System History
Rows
Part of my history
Mold exposure
Yeast infections (oral, intestinal, skin, groin vaginal)
Exposure to Lyme endemic area
Tick bite and/or bulls eye rash
Other major insect bites
Mercury amalgams
Other heavy metal exposure
Multiple allergies
Chemical sensitivity
If you indicated any of these symptoms, please note below the date of occurrence or diagnosis and any treatment received.
Cardiovascular History
Rows
Part of my history
Heart attack
Chest pains
Rhythm problem
Pacemaker
Valve problem
If you indicated any of these symptoms, please note below the date of occurrence or diagnosis and any treatment received.
Neurological History
Rows
Part of my history
Stroke
Traumatic brain injury
History of whiplash
Concussion
If you indicated any of these symptoms, please note below the date of occurrence or diagnosis and any treatment received.
Female Breast
Rows
Part of my history
Abnormal radiological study (i.e. mammogram)
Chest or rib trauma
Neck or shoulder trauma
Trauma or injury to breast(s)
Breast lump(s)
If you indicated any of these symptoms, please note below the date of occurrence or diagnosis and any treatment received.
Well done! Let's keep going. Now let's learn about your Diagnosis History. Please click on any issues you are currently dealing with. (Any cancer diagnosis information will be found in the following section).
Medical Concerns
Rows
Ongoing issue
Past Issue
Sun poisoning
Chronic fatigue
Multiple Chemical Sensitivities
Graves Disease
Hashimotos Thyroiditis
Arthritis
PMS
Fertility disorder
Migraines
Myalgia
Lyme Disease
If you indicated any of these conditions, ongoing or present, please note below the date of occurrence or diagnosis and any treatment received. If you have not tried or are not now having treatment write "none" if applicable.
Cancer History
Rows
Part of my history
Brain
Bone
Breast
Colon
Leukemia
Prostate
Thyroid
Skin
Other cancer diagnosis not listed above
If you indicated any of these cancers are part of your history, please tell us about the method of diagnosis (e.g. MRI, biopsy, bloodwork, etc.), year of diagnosis, and treatment your received.
Your Surgical History. Please list any surgeries you've had. Include the reason for the surgery, what year it/they occurred and if there were any complications during or after. (For example, hysterectomy, reason was for painful menses, Jan 2001, complication was scar tissue formation)
History of Injuries - please complete accordingly. Include the type of injury, details, date of the injury, your age at the time of injury and any symptoms that occurred afterward (example: broken collar bone, gymnastics fall, November 1995, age at time of injury 10, symptom afterward was neck pain)
Female History
(skip this if you are biologically a male)
Are you....
Post menopausal
Peri-menopausal
Having menstrual periods
If you are post- or peri-menopausal, indicate age of onset below.
At what age did your menses begin?
Were your menses........
painful
heavy
abnormal
none of these
Other
Are your menses now....
painful
heavy
abnormal
other
History of Hormonal Support. Are you taking any female hormone support? (Tell us if this includes birth control and or bioidentical hormones).
What is the date of your last mammogram?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What were the findings of this mammogram? Have you had any other breast studies such as MRI, ultrasound or biopsy? Tell us about this here:
Allergies. Click next to any allergies you may have. We will cover food allergies in a different section. If you do not have any allergies, please click 'none'.
*
Environmental
Medications
Chemical
Herbal/Supplements
None
Other
If you indicated any of these allergies, please tell us about the type of allergy, the degree of the allergy (mild, moderate, severe) and what kind of reaction you experience.
Family History - please click on any of the following included in your family medical history.
Rows
In family history
Obesity
Cancer
Thyroid Disorder
Auto Immune Disease
Lyme Disease
Multiple Chemical Sensitivity
Diabetes
If you indicated that any of these conditions are in your family history, please tell us about type of illness (if applicable) and which family member had the condition. (e.g. X Cancer, Family History, Colon Cancer, Father). Write the family member with such history. We are most concerned about your immediate family members: mother, father, children, brother/sister, grandparents.
Your Supplements. Please tell us the names of any supplements you take on a regular basis. Include name, dose, and frequency. If you do not take any supplements, please write none.
*
Your Medications. Please tell us the names of any prescription medications you take on a regular basis. Include name, dose, frequency and the individual who prescribed it. If you do not take any medications, please write none.
*
If it is more convenient for you to do so, you may upload a document of all your medications and supplements here.
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Have you received any vaccinations within the last 5 years? If yes, please give explanation with dates. If no, please write none.
*
Have you received any covid vaccines? If so, please indicate what kind and when.
*
Tell us about your dietary habits
Click on all the following food groupings that best reflect your current diet
*
Vegan - no animal sources of food, all plant based
Vegetarian - dairy, eggs, and/or fish are only animal sources - mostly plant-based
Mixed - 1/2 animal sources, 1/2 plant sources
Heavy animal sourced - more than 1/2 of diet is from animal sources, little plants
Diet mostly processed/prepared foods (including restaurants)
Diet 50/50 with processed and whole foods prepared at home
Diet mostly whole foods prepared at home
I don't buy any organic foods
I buy some organic and/or non-GMO
I buy mostly organic and/or non-GMO
I buy ALL organic and/or non-GM/grass-fed/free range
Describe your typical breakfast
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Describe your typical lunch
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Describe your typical dinner
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Describe your typical snacks
*
Describe beverages you typically drink
*
How would you describe your childhood diet?
*
Have you ever experimented with certain dietary regimens and if so, what were your responses?
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Please check any food allergies/sensitivities AND/OR foods you're currently avoiding for other reasons
Gluten
Wheat
Dairy
Soy
Legumes
Nuts
Corn
nightshades (potatoes, tomatoes, peppers, eggplant, ashwaganda, goji berries)
Other
Did you click "Other"? Tell us more here
Do you have any relevant previous lab work and/or other medical history documents from other providers? If yes, please bring them with you to your appointment.
*
Yes
No
Alternatively, you may upload those documents here.
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Drag and drop files here
Choose a file
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We recognize that our form unfortunately does not allow you to unselect an option if you clicked on it accidentally. If you mistakenly clicked on something that is not actually part of your history, please note it here:
Wait! One more thing. Don't forget to save your work by verifying that you are human and clicking on Submit. Thank you for telling us all about your health. Dr. Rind and his team look forward to helping you with your health goals.
Please verify that you are human
*
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