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New Patient Registration Forms old version

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