Patient Information
Name___________________________________________________________________________________________
Address_________________________________________________________________________________________
City________________________________________State_________________________Zip_____________________
Phone: Home (_____) – _____-________ Office (_____) – _____-________ ext._______
Cell (_____) – _____-____________
E-mail____________________________________________________________________
EMERGENCY NOTIFICATION
In case of emergency, notify:________________________________________________________________________
Address_________________________________________________________________________________________
City_____________________________________________State__________________Zip_______________________
Phone: Home (_____) – _____-_________ Office (_____) – _____-_________ ext._____
Cell (_____) – _____-____________
E-mail __________________________________ How related? ________________________
PERSONAL DATA
Sex: Male Female
Age:__________Date of Birth _____________
Allergies_______________________________________
Height: Feet ____________ Inches ___________ Weight _______________________
Blood Type _____________________
Ancestry:
Caucasian Asian African Hispanic Other _____________________________
Marital Status:
Married Single Widowed Divorced If married, how long? ________________________________
Children?
Yes No How Many? Girls ________ Boys ________ Ages ______________________________________
Occupation _____________________________________________________
How many years? ______________________
OTHER
How did you hear about Health Consultations with Dr. Myatt? ___________________________________________________
How do you prefer to pay for your consultation (circle one) Visa/MC Check
Visa/MC # _____________________________________________
Expiration Date _________________________________ CVV___________
Authorization Signature ___________________________________
Today’s Date __________________________________
Please make checks payable to: Dr. Dana Myatt. Payment by check must be received in advance.
Dr. Dana Myatt / 2535 N Beech Blvd, Camp Verde, AZ — Phone: 1 – 800 – Dr. Myatt (367 – 9288)
www.DrMyattsWellnessClub.com
When did you last have a complete physical exam?___________________
Diet: Record all food and drink, with appropriate amounts, for three (3) days. Attach an extra sheet if needed.
Day 1
Breakfast
Lunch
Dinner
Snacks
Beverages
Day 2
Breakfast
Lunch
Dinner
Snacks
Beverages
Day 3
Breakfast
Lunch
Dinner
Snacks
Beverages
Environment: Please check any of the following that you are exposed to:
Live or work around people who smoke.
Drink tap water.
Live or work in a city with polluted air.
Exposure to chemicals at work. (Please list)
Stress Index: Please rate each of the following as they currently apply to you.
Marriage / Relationship: Good | O.K. | Stressful (describe)
Personal Health: Good | O.K. | Stressful (describe)
Work: Good | O.K. | Stressful (describe)
Health of Family: Good | O.K. | Stressful (describe)
Children (relationship): Good | O.K. | Stressful (describe)
Finances: Good | O.K. | Stressful (describe)
Other (please list)
Exercise: Check the exercises you do, with how often and how long.
Aerobic
Weight training
Flexibility
Other (name)
Habits: Check which substances you use and describe how much.
Caffeine
Tobacco
Alcohol
Soda Pop, Energy Drinks, Sports Drinks, etc.
Drugs (nonRx)
Other
Rest and Relaxation: Check the amount of each that you receive.
Sleep: hours/night
Relaxation: hours/day
Meditation: hours/day
Hobbies: hours/day
Other: (describe)
PHOTO
Please affix a recent photo of yourself in this space:
If photo is larger than this space, DO NOT CROP.
Affix with a paperclip, if available.
CURRENT HEALTH CONCERNS:
Please list below the Main Complaints you have, in ORDER OF IMPORTANCE to you and tell when this complaint began.
1.
2.
3.
4.
5.
Personal Health Goals: Please describe what you hope to accomplish.
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
FAMILY HISTORY: Check if your relatives have had any of the following and their relationship to you:
Allergies
Heart Disease, Stroke
Asthma, Hay fever
High Blood Pressure
Birth Defects
High Cholesterol
Cancer
Kidney Disease
Diabetes
Mental Illness
PAST MEDICAL HISTORY: Please list all serious illnesses, injuries, and surgeries that you have had in the past with the date of the occurrence and the outcome:
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
MEDICATIONS: List all prescription and non-prescription medications, nutritional supplements and herbs you are currently taking, including dose.
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
ALLERGIES: To medications, foods, or substances.
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
INSTRUCTIONS: Check all medical conditions that you currently have or that you have had in the past one year, or that you are currently receiving treatment for.
? alopecia
? ALS
? Alzheimer’s disease
? anemia
? angina
? anxiety
? appendicitis
? arthritis, osteo
? arthritis, rheumatoid
? atherosclerosis
? athlete’s foot
? asthma
? attention deficit disorder
? back pain
? bladder infections
? blood clots
? boils
? bone spurs
? bronchitis
? bruises, bruise easily
? bulimia
? bursitis
? cancer
? Candidiasis
? canker sores
? cardiac arrhythmia
? cardiovascular disease
? carpal tunnel syndrome
? cataracts
? celiac disease
? cholesterol, elevated
? chronic fatigue syndrome
? chronic obstructive pulmonary disease (COPD)
? cold sores
? colitis
? common cold, recurrent
? congestive heart failure
? constipation
? Crohn’s disease
? Cushing’s disease
? cystitis
? depression
? dermatitis
? dermatitis herpetiformis
? diabetes, type I
? diabetes, type II (adult onset)
? diarrhea
? diverticulitis
? diverticulosis
? ear infections
? eczema? emphysema
? endometriosis
? epilepsy
? Epstein-Barr syndrome
? fibrocystic breast disease
? fibromyalgia
? fungal skin infection (tines)
? fungus under nails
? gallstones
? gastritis
? glaucoma
? goiter
? gonorrhea
? gout
? Goodpasture’s disease
? Grave’s disease
? Hashimoto’s thyroiditis
? hay fever
? headaches
? headaches, migraine
? hearing problems
? heart disease
? hemorrhoids
? hepatitis
? hernia
? herpes
? high blood pressure (hypertension)
? hives/urticaria
? hyperthyroid (over active thyroid)
? hypothyroid (under active thyroid)
? hypoglycemia
? idiopathic thrombocytopenic purpurea (ITP)
? impotence
? indigestion
? infections
? infertility
? insomnia
? iritis
? irritable bowel syndrome
? joint pain
? kidney disease
? kidney stones
? liver disease
? lupus (SLE)
? Lyme disease
? macular degeneration
? memory loss
? Meniere’s disease
? mononucleosis
? Multiple Sclerosis (M.S.)
? muscular dystrophy
? myasthenia gravis
? myelitis
? neuralgia
? neuritis
? neuropathy
? obesity
? osteoarthritis
? osteoporosis
? panic attacks
? parasites,intestinal
? Parkinson’s disease
? pemphigus
? periodontal disease
? pernicious anemia
? phlebitis
? pneumonia
? polymyalgia
? premenstrual syndrome
? prostate enlargement
? prostatitis
? psoriasis
? rheumatic fever
? rheumatoid arthritis
? rosacea
? scleroderma
? seborrheic dermatitis
? shingles (herpes zoster)
? sinus infection
? Sjogren’s syndrome
? stroke
? tachycardia
? tendonitis
? thyrotoxicosis
? tinnitus (ringing in the ears)
? tuberculosis (TB)
? tumors, benign
? ulcer, duodenal
? ulcer, gastric
? ulcer, skin
? uremia
? urination problems (frequent urination)
? vaginal infections
? varicose veins
? venereal disease
? vitiligo
? warts
? weight gain
? weight loss
List below any other medical diagnoses or conditions not listed elsewhere on this form.
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