NOTE: PDF, Adobe Reader required.
Download a copy of New Patient General Information & Patient History and a Chief Complaint. These are electronic ‘fill-in’ forms. After you have filled in the answers please save a copy to your computer. If specified in the Chief Complaint document, gather copies of medical records which have been specified as well as prepare other requested materials.
General Patient Information & Health History
New Patient General Info & Health History Forms
Chief Complaints
Read through each of the eleven Chief Complaint categories to locate your specific complaint. If you do not locate your specific disorder(s) or condition(s) use the twelfth (12th) category “Other Chief Complaint” to submit your information.
Note: If you are a Stroke, TBI or PCS patient please submit Chief Complaint forms from categories 1a, 1b, and/or 7 along with 8.
1a. Brain-based Neurological –
Sensory: Balance Difficulty, Dizziness, Double Vision, Hearing Loss, Meniere’s Disease, Tinnitis, Vertigo, Vision Loss
Twitches & Shakes Involuntary: Ataxia, Chorea, Chronic Fatigue Syndrome, Coma, Essential Tremors, Tourette Syndrome
Swallowing: Dysphagia, Painful swallowing, Globus (lump sensation in throat)
Speech Motor: Apraxia, Spasmodic Dysphonia, Vocal Cord Paralysis
Adult CC 1 Neurological Disorders Adult
Child CC 1 Neurological Disorders Child
1b. Aphasia and Memory Loss
Aphasia: Anomic, Expressive, Receptive, etc
Memory Loss: Short-term, Long-term, Visual, etc.
CC 1a Aphasia_Memory Loss_ Speech Language
2. Ear, Nose, Throat & Respiratory:
Ear, Nose & Throat: Chronic Colds & Flu, Difficulty swallowing, Ear Infections, Sinusitis, Sore throat Note: Tinnitis or Hearing Loss above Brain-based Neurological: Sensory
CC 2 Ear, Nose & Throat
Respiratory: Asthma, COPD, Emphysema, Recurrent Bronchitis, Pneumonia Prevention
CC 2 Respiratory
3. General Health:
Allergies, Colds & Flu, Dizziness, Hepatitis, Lack of appetite, Weight Gain & Loss
AIDs and HIV Managed Care
Anemia, Bruising, Low Blood Pressure, Polycythemia, Poor circulation
Hypertension, High Cholesterol & Triglycerides, Vascular disease, Edema
CC 3 General Health
Fatigue CC3 Fatigue
Insomnia CC 3 Insomnia
Stress CC 3 Stress
GI Disorders: Abdominal Pain, Acid reflux, GERD, Gluten Sensitivity, Bloat & Distention, Constipation, Colitis, Crohn’s, Diarrhea, Hemorrhoids, IBS, Nausea & Vomiting, Poor digestion, Ulcers (Stomach or Intestinal) CC 3 GI Disorders
4. Gluten Sensitivity Treatment or Advanced Testing
Blood testing for Gluten sensitivity, Gluten Reactive Foods and/or Autoimmune Disease CC 4 Gluten Sensitivity
5. Metabolic:
Diabetes Type II – Insulin Resistance, PCOS, Thyroid disorders CC 5 Metabolic Thyroid Diabetes PCOS
Weight Loss or Obesity CC 5 Weight Loss & Obesity
6. Pain:
Type I: Complex Regional, Fibromyalgia, Herpes Zoster, Phantom & Residual Limb, Plantar Fascitis, Restless Leg Syndrome CC 6 Physical Sensation Pain Numb Tingling
Type II: Arthritis (Osteo & RA), Back, Neck, Joint-Muscle, Menstruation, PMS, TMJ, Toothaches, Post Birth, Post Surgery CC 6 Physical Sensation Pain Numb Tingling
Type III: Headaches, Migraines CC 6 Headaches & Migraine
7. Paralysis: due to Non-spinal cord injury:
Stroke, TBI, PCS, Multiple Sclerosis, Motor Neuron Disease, White Matter Disease, degenerative disease
Monoplegia, Quadraplegia, Dysphagia, Bell’s Palsy
CC 7 Paralysis Post Stroke, TBI, PCS
8. Heart Attack or Stroke Prevention:
Arrhythmias, Coagulation Issues, High Cholesterol, High Triglycerides, Hypertension, Polycythemia, Vascular disease
CC 8 General Health Post Heart Attack or Stroke
9. Emotions, Psychological & Mental:
Emotional: Anxiety, Adult Attention Deficit, Bi-polar, Bi-polar Personality, Depression, Eating Disorders, OCD, PTSD, Anger-rage, Fear, Excess grief, Mood swings
CC 9 Shen Psych Emotion
Mental-Neurological: Alzheimer’s, Dementia, Memory Loss, Parkinson’s, Schizophrenia
Forms will be online after December 20
Substance Withdrawal Support & Addiction Recovery: Psychotropic Drug Side Effects or Withdrawal, Alcohol or recreational drug recovery support
Forms will be online after December 20
10. Reproductive & Urogenital:
Men: Andropause, Erectile Dysfunction, Impotance, Protatitis, BPH, Low libido
CC 10 Male Prostatitis ED Impotent
Women: Perimenopause, PMS, Menstruation Pain, Low Libido, Amenorrhea, Dysmenorrhea
CC 10 Gynec PMS Irreg Cycles Painful Menses
Men & Women: Bladder, Urination difficulty, Painful urination, Recurrent UTI, etc
CC 10 Male & Female Urogen Bladder Urination UTI
Men & Women: Fertility
CC 10 Male & Female Fertility
11. Complex Case Patients
These documents are for patients seeking care of the following conditions;
1) Autoimmune Diseases: Hashimoto’s, Lupus, Rheumatoid Arthritis, HIV/AIDs, Inflammatory Conditions, etc
2) Mysterious Undiagnosed Condition(s) seeking diagnosis and/or treatment
3) Current Treatments are not yielding good results
Complex Case Master Fill_In Complete instruction are located on page 2 of the document.
12. Other Chief Complaint
Use this form if your Chief Complaint is not listed above.
CC 12 OTHER To Be Identified or Described by patient
by Blake Farmer Feb. 16, 2012