Patient entry form

Please fill out the patient entry form as best you can.

Name *

First

Last

Gender *

• Male
• Female

Contact Number (Include International Code) *

Email *

Mailing Address

Height

Weight

Date of Birth

DD-MM-YYYY

Emergency Contact Name

Emergency Contact Details (Include International Code)

Blood Type

Health Condition(s) you would like to treat

Have you ever had an allergic reaction?

• Yes
• No

If Yes, what are you allergic to?

What happens to your body when you have an allergic reaction?

What is your daily alcohol consumption?

• None
• 1-2 units
• 3-4 units
• Over 4 units
• Only drink at weekends

Do you smoke?

• Yes
• No

Are you currently on any medications?

• Yes
• No

If yes, what medications?

Are you allergic to any medications?

• Yes
• No

If yes, what medications?

What is the date of your last vaccination, if any

DD-MM-YYYY

Have you ever been diagnosed with any of the following medical conditions?

• Cancer
• Leukemia
• Anxiety
• Diabetes
• Hypertension
• Arthritis
• Lung problems
• Mental Disorder, i.e. Schizophrenia
• Kidney Problem
• Thyroid
• Prostate Problem
• Fatigue
• Stroke
• Hormonal Issues
• Heart Problems
• Hepatitis
• Tuberculosis
• Sexually Transmitted Diseases (Gonorrhea, syphilis, or other)
• Other
• No previous medical condition

If so, what is your current primary diagnosis/objective?

Secondary diagnosis/objective, if any?

Have you been diagnosed with cancer?

• Yes
• No

If yes, state what type of cancer(s)

When was it diagnosed?

DD-MM-YYYY

What is the current status?

Do you have any health condition(s) concerning your cardiovascular system?

• Yes
• No

Please tick if you have any of the following condition(s)

• Myocardial Infarction (Heart Attack)
• 

Angina Pectoris (Angina – Chest Pain)
• 

Tachycardia (Heartbeat exceeds normal range)


• Bypass Surgery
• 

High Blood Pressure
• 

Low Blood Pressure
• 

Other

When was it diagnosed?

DD-MM-YYYY

Do you have any health condition(s) concerning your neurological system?

• Yes
• No

Please tick if you have any of the following condition(s)

• 

Vision Impairment


• Black Spots
• 

Nystagmus
• 

Muscle Weakness/Wasting (Eg. Difficulty walking or maintaining posture)


• Hyperreflexia (Overly active reflexes)
• 

Decreased Hand Strength
• 

Fainting


• Speech Problems
• 

Numbness in Extremities


• Tingling Sensation or Twitching


• Decreased Sense of Touch
• 

Spasticity (Stiff or rigid muscles)
• 

Hypo-reflexia (Basic hammer reflexes are reduced or absent)
• 

Depression


• Sleep Disturbance


• Dizziness
• 

Chronic Migraines
• 

Headaches
• 

Vertigo (Room spinning)


• Reduced Vitality
• 

Obstructive Sleep Apnea (Not breathing normally or snoring)


• Other



When was the condition diagnosed? 


DD-MM-YYYY

Do you have any health condition(s) concerning your circulatory system?

• Yes
• No

Please tick if you have any of the following condition(s)

• 

Poor Arterial Circulation
• Poor Venous Circulation


• Leg Cramps


• Tired Legs


• Swollen Ankles


• Varicose Veins
• 

Tingling in Arms and Legs


• Falling Asleep Hands/Legs
• 

Leg Ulcers


• Other

Do you have any health condition(s) concerning your gastrointestinal system?

• Yes
• No

Please tick if you have any of the following condition(s)

• Acid Indigestion


• Bloating
• 

Ulcer
• 

Loss of Appetite
• 

Rapid Weight Gain
• 

Rapid Weight Loss
• 

Overweight Problem


• Pancreatitis
• 

Hepatitis A
• 

Hepatitis B


• Gall Stones


• Diarrhea
• 

UI (Urinary / urinary tract infections
• 

Other


Do you have any health condition(s) concerning your pulmonary system?

• Yes
• No

Please tick if you have any of the following condition(s)

• Asthma
• Chronic Bronchitis
• Emphysema
• Tuberculosis
• Chronic Cough
• Chronic Sinusitis
• Sinus Headaches
• Chronic Allergic Rhinitis
• Chronic Cold
• Allergic Sinus Problem
• Chronic Nose Bleeds
• Other

Do you have any health condition(s) concerning your rheumatic disease?

• Yes
• No

Please tick if you have any of the following condition(s)

• Soft Tissue Rheumatism
• Joint Pain
• Articular Rheumatism
• Rheumatoid Arthritis
• Back Pain
• Other

Do you have any health condition(s) concerning your Endocrine system?

• Yes
• No

Please tick if you have any of the following condition(s)

• Diabetes Mellitus
• Thyroid Dysfunction – Overactive
• Thyroid Dysfunction – Underactive
• Adrenal Gland Dysfunction
• Menopause (Hot flashes etc.)
• Male (Low libido)
• Other

Do you have any family member(s) that have the following medical conditions?

• Cancer
• Leukaemia
• Anxiety
• Diabetes
• Hypertension
• Arthritis
• Lung
• Thyroid
• Kidney
• Prostate
• Fatigue
• Hormone
• Heart
• Stroke
• Mental Disorder/Neurological
• No previous medical conditions

No previous medical condition

Please state any genetic disorder(s) of which you are aware of

Have you been hospitalized before?

• Yes
• No

If yes, when is your last hospitalization date?

DD-MM-YYYY

Please list all past medical issues and/or surgeries (State date of occurrence, type of treatment received and results)

Please state if you have received hormone therapy (If yes, please state the duration for the therapy and the number of IU’s of HGH injected per week)

Please state if you have any metal plates/rods or implanted device or tissue that should be known to the doctor (Describe current status, diagnosis or prognosis)

Please state if you have communicable illness such as HIV, TB and/or Hepatitis, etc. (Describe current status, diagnosis or prognosis) 


Please state if you have a pacemaker, continuous medication pump and/or feeding tube (Explain why and what type)

Are you on ventilator and/or have breathing problems?

• Yes
• No

Have you had a tracheotomy?

• Yes
• No

[FOR MEN ONLY] When was the date and result of your last PSA test, if any?

[FOR WOMEN ONLY] Do you have periodic mammograms?

• Yes
• No

[FOR WOMEN ONLY] Do you have periodic mammograms?

DD-MM-YYYY

Additional Medical Information

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