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Aug 2019 www.ChelationMedicalCenter.com
NEW PATIENT PERSONAL INFORMATION www.ChelationMedicalCenter.com
Patient’s full name: ___________________________________ Today’s date: ___/___ /___
Address: _______________________________________ Birth date ____/____/____ Sex: M / F
City: ________________________________________ State: _____ Zip: ___________
Home phone: (_____) ____________________ Work: (_____) ____________________
Cell: (_____) ____________________ Permission to text message? __ YES ___ NO
E-Mail ______________________________________ SSN (optional) __________________
Spouse's or Parent’s name(s) ____________________________________________________
Who referred you or how did you hear about us? ______________________________________
FINANCIAL INFORMATION: responsible party name: __________________________________
Relationship ___________ address (if different) ___________________________________
IN CASE OF EMERGENCY NOTIFY: _______________________ Phone (____)____________
Payment for Services:
Payment is due at the time services are rendered. We do not accept Payments from third parties
such as Insurance companies, Medicare or Maine Care.
Primary Care Doctor: ______________________________ phone # ____________________
We recommend that our patients have a primary care physician for routine problems, acute illness
and hospital admissions. If you agree to have Dr. Psonak discuss medical issues with your primary
care doctor, sign here: ___________________________________ date: ___/___/___
I UNDERSTAND that the approach of Chelation Medical Center, LLC and Dr. Psonak to medical
problems is from a perspective that may differ from what may be considered the conventional or
standard therapy of the medical community.
I also understand that the office is fragrance free. Anyone entering the office must avoid the use
of perfume, after-shave, fragrances or residue of smoke on their clothes, otherwise they will
be asked to leave and another appointment will be set for them. Please ask if you should
come in fasting for your visit.
Patient or Guardian Signature: ____________________________________ Date: ___/___ /____
Apr 2019 www.ChelationMedicalCenter.com Page 1 of 11
Medical History Today’s Date __________________
Patient Name _____________________________________ Date of Birth _________________
Your Height: _____________ Your Weight: ______________
Main Problems (Chief Complaint):
List the main problems that you wish to address - current medical problems/date started ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
YOUR SYMPTOMS (History of Main Problems): Please list any symptoms that you have now or experienced: (Please check past or present and how severe and frequent the problem)
Past Present How severe How Frequent
1. Headaches
2. Problems with vision, hearing, taste or smell
3. Chest Pain or shortness of breath
4. Cough, wheezing or other difficulties
5. Heartburn, gas, bloating, indigestion
6. Constipation, diarrhea, hemorrhoids
7. Urinary tract problems, stones, infections in the bladder or kidney
8. Gynecologic problems(specify)
9. Infertility, impotence, low libido
10. Skin or hair problems
11. Bone or joint disorders
12. Neurological problems, Fasciculations
13. Mood, emotion, or psychiatric problems
14. Fatigue, night sweats, loss of motivation
Allergies or adverse drug reactions: (List Known Allergies to medication and type of reactions)
___________________________________________________________________________________
___________________________________________________________________________________
Other Allergies: Check all that apply:
Dairy Wheat Corn Eggs Peanuts shellfish Chemicals DON’T KNOW
Do you react to pollen? Yes No Reaction __________________________
Do you react to molds? Yes No Reaction __________________________
Do you react to foods? Yes No Reaction __________________________ Blood Type: Do you know your blood type? (Circle One) O A B AB (Circle One) Positive or Negative
Apr 2019 www.ChelationMedicalCenter.com Page 2 of 11
MEDICATIONS & NUTRITIONAL SUPPLEMENTS
Medications: Include all prescription and over the counter medications that you are currently taking
Prescription medications Dose How often taken
Nutritional supplements: Include all vitamins, minerals, herbals & other supplements that you are currently taking (attach extra page if necessary) Name Manufacturer Dosage and Frequency Office use only
HISTORY OF MEDICATIONS TAKEN IN THE PAST: Have you ever taken any of the following medications?
Lipid lowering (Statins, etc.) Name: _____________________ Duration: _________ When stopped? __________
Osteoporosis (Phosomax, etc.) Name: ___________________ Duration: _________ When stopped? __________
Antibiotics Name: _____________________ Duration: _________ When stopped? __________
Hormone medications Name: _____________________ Duration: _________ When stopped? __________
Other long term prescription drugs you have taken in the past:
Name: ___________________________ Duration: _____________ When stopped? _____________
Name: ___________________________ Duration: _____________ When stopped? _____________
Name: ___________________________ Duration: _____________ When stopped? _____________
Apr 2019 www.ChelationMedicalCenter.com Page 3 of 11
Date of last medical checkup _________ Results ________________________________
Names of recent Doctors consulted ___________________________________________
Have you had adjustments or other treatments for your neck or back? Yes No
Habits:
Do you smoke? No_____ Yes_____
If yes, how many packs per day?___________________________
If you have quit, how long ago? ________________________
Do you use alcohol? No_____ Yes_____
If yes, how often do you drink?____________________________
Do family or friends worry about your alcohol intake? _________
Have you ever had problems with drug use?__________________
Please indicate past or present amounts:
Daily Weekly Occasionally Never Past
Coffee/caffeine
Aspirin
Laxatives
Exercise
Meditation
REVIEW OF SYSTEMS:
Skin: Acne Dry Liver Spots Rash White Bumps Ridged Nails
Athlete’s Foot Eczema Oily Redness White Patches Spoon Shaped Nails
Bruising Hair Loss Pale Rough Yellow Tone White Spots on Nails
Burning Feet Herpes Peeling Skin Tags Bluish Lips
Cracks Hives Poor Wound Healing Vitiligo Deep Red Lips
Dandruff Itching Psoriasis Warts Pale Lips
Eyes: Bags Under Cataracts Diplopia Floaters Light Sensitive Sclera blue Swollen Lids
Blurred Vision Crusty Lids Discharge Freq. Blinking Pain Sclera White Tearing
Burning Dark Circles Dyslexia Glaucoma Bloodshot Styes
Ears: Discharge Excessive Wax Infection Red Ear Lobes Sound Sensitive Vertigo
Ear aches Hearing Loss Itching Ringing Tinnitus
Pressure
Nose & Sinuses: Crusts Freq. Colds Itching Nose Bleeds Sinus Trouble Stuffiness
Discharge Hayfever Mucus Yellow Polyps Sneezing Asthma HX
Mouth & Throat: Amalgams Canker Sores Silver Fillings Gag Easily Grind Teeth Lines on Tongue Mouth Ulcers
Bad Breath Chapped Lips Dentures Gingivitis Hoarseness Lips Crack Red Tip Tongue
Bridges Coated Tongue Drooling Glossy Tongue Implants Magenta Tongue Root Canals
Bleeding
Gums
Crowns Freq Sore
Throats
Gold Fillings Infections Metal Braces Sore Tongue
Apr 2019 www.ChelationMedicalCenter.com Page 4 of 11
Respiratory: Apnea Bronchitis Difficulty Breathing Pleurisy Shortness in Breath Smoke: Y or N
Asthma Congestion Cough Pneumonia Wheeze Packs per Day __________
Cardiac: Cold Extremities Dyspnea Flushing of Skin High B/P Palpitations Atherosclerosis: Y/N _______
Chest Pain Edema Heart Murmur Low B/P Tight Chest HX of Heart Surgery _____________
Gastrointestinal: How often do you have a bowel movement? ______________ What is color of stool? _____ Abdominal
Pain
Bloating Difficulty
Swallowing
Gall Bladder
Removed
Irritable
Bowel
Nausea Ulcers
Anal Itching Colitis Diarrhea Heartburn Ingestion Regurgitation Vomiting
Belching Constipation Flatulence Hemorrhoids Mucus Tan Stool Fat intolerance
Urinary: Burning Frequency Incontinence Kidney Disease Polyuria Urgency Dark Yellow Urine
Cystitis Hesitancy Infections Nocturia Stones Pale Urine
Genital (male): Discharge Impotence Itching Prostatic Hypertrophy Testicular Pain
Genital Herpes Infertility Painful Urination Sores Infection
Genital (female): Birth Control
Pills
Excess Hair
Growth
Genital Herpes Infertility Menopausal
Symptoms
Tender Breasts
Discharge Endometriosis Hot Flashes Irregular Cycle PMS Yeast Infections
Dysmenorrhea Low Libido Hysterectomy Itching Spotting Excess Bleeding
Musculoskeletal: Arthritis CP Hx of Fractures Joint Swelling Muscle Weakness Spasticity
Atrophy Fibromyalgia Hypotonia Limited Range/Motion Rigidity Stiffness
Backache Gout Joint Pain Muscle Pain Spasms Uneven Muscular
Development
Neurologic: Abnormal
Gait
Excessive
Sleepiness
Poor
Coordination
Learning
Problems
Poor Dream
Recall
Shaky Feeling Unprovoked
Anger
ADD Delusional Hyperactivity Mood Swings Poor Memory Speech Delay Weakness
ADHD Depression Impulsiveness Nervousness Rage Behavior Tension Withdrawal
Anxiety Disoriented Insomnia Nightmares Restlessness Tics Autistic Features
Apathy Confusion Irritable Numbness Sciatica Tingling Fasciculation
Brain Fog Fainting Headaches PDD Seizures Tremors Unable to Walk
Endocrine: Coarse Features Cold Intolerance Excessive Thirst HRT Hypothyroid Underweight
Edema Excessive Hunger Fatigue Hyperthyroid Carb Intolerance Diabetes Hx
Dysinsulism Excessive Swelling Heat Intolerance Hypoglycemia Overweight
Immune: Autoimmune Cancer Hx Hepatitis Hx Lupus Recurrent Illness Blood Transfusion
Breast Implants CFS Hx Infection Lyme Hx Swollen Glands
Allergic to
everything
Chronic
Fatigue
Chemical Intolerance Dental Implants Universal Reactor
Apr 2019 www.ChelationMedicalCenter.com Page 5 of 11
Social History:
Please list all countries you have traveled to or lived in the past: ________________________
____________________________________________________________________________
Where was your place of birth? _____________________________________________
States where you lived in the past: __________________________________________
Does your spiritual life play an important role in your life? Yes No
First Partnered ____ Number of years ____ Divorced/separated _____ When ____
Number of children ____ Ages/Gender _______________________
ILLNESSES & DISEASES (Past Medical History):
Date of last complete checkup _____________ Results _______________________________
Names of recent Doctors consulted ________________________________________________
Have you had adjustments or other treatments for your neck or back? Yes No
TRAUMATIC EVENTS (Past Medical History):
Please list all Accidents and Injuries:
Please list any surgeries (operations), reason for the surgery, and date of surgery:
Please list other diseases from which you currently suffer or have suffered if not already described:
Please list other traumatic events: (for example, loss of close relationships by death, illnesses, divorce; major life changing events, major moves, major job changes, etc.):
WOMEN ONLY
Number of children ____ Ages/Gender ___________________________ Adopted______
Number of: Pregnancies _____ Deliveries ______ Miscarriages _____ Abortions _____
Do you use a contraceptive? Yes No If so, what type _________________________
Last Pap smear _____________ Result ____________ Last mammogram ____________ Result _________
Have you had a scan DEXA for bone density? Yes No Result _____________________
Are you taking hormone replacement therapy? Yes No What form? ________________
Apr 2019 www.ChelationMedicalCenter.com Page 6 of 11
FAMILY HISTORY: Place an “X” in appropriate boxes to identify all illnesses/conditions in your blood relatives
Illness/Condition Family Member grandparents father mother brother sister son daughter other
Allergies
Asthma
Cancer (specify)
Heart disease
Stroke
Lung disease (specify)
Diabetes
High blood pressure
Liver disease
High cholesterol
Alcohol/drug abuse
Neurologic disease
(specify)
Depression/psychiatric
illness
Genetic (inherited)
disorder
Other
WORK HISTORY & ENVIRONMENT
Current Occupation: ____________________________________ How Long? _______________
Past Occupations: ______________________________________ How long? _______________
_____________________________________ How long? _______________
_____________________________________ How long? _______________
Apr 2019 www.ChelationMedicalCenter.com Page 7 of 11
HOME ENVIRONMENT
Apr 2019 www.ChelationMedicalCenter.com Page 8 of 11
Apr 2019 www.ChelationMedicalCenter.com Page 9 of 11
OTHER ENVIRONMENTAL EXPOSURES
HOBBIES / SPORTS: ______________________________________________________________
___________________________________________________________________________________
List any chemicals, metals, dusts, molds, or fumes to which you are repeatedly exposed ___________________________________________________________________________________
___________________________________________________________________________________
Do you have or have you had a toxic exposure such as mold in your home? Which one?
___________________________________________________________________________________
___________________________________________________________________________________
Do you see a dentist regularly?________ Name of Dentist: __________________________________
How many silver fillings did you have? ____ How many silver fillings do you have now? _____
How many root canals do you have? _______ Any tooth implants? __________
Have you had your fillings removed? _____ When? __________ Natural Dentist? ________
Apr 2019 www.ChelationMedicalCenter.com Page 10 of 11
DIET HISTORY:
1. Do you follow a special diet? Yes No Organic certified? Yes No 2. What is your primary source of water? (Circle One) Tap Well Bottled Filtered 3. How often do you consume fish per week? _______ 4. What kinds of fish do you eat?________________________________________ 5. How many slices of bread do you eat daily?________ Kind of Bread?_________ 6. How many glasses of milk daily?_____ Kind of milk consumed?______________ 7. How many cups of coffee per day? _____ Decaf _____ Regular _____ Organic 8. How many cups of tea per day? _____ Decaf _____ Regular _____ Organic 9. Is margarine or butter used most of the time?____________________________ 10. What kind of oil do you cook with? ____________________________________ 11. Are most meals consumed at home, restaurants or fast food?________________ 12. Are sugar substitutes used? _________ Which ones?_______________________ 13. Are you or have you ever been a vegetarian?______________________________ 14. Do you eat wild local game (venison)?___________________________________ 15. Were you breast fed? _________ How long? _____________________________ 16. What are your favorite deserts?________________________________________ 17. What is your favorite food?____________________________________________ 18. List foods you do not like _____________________________________________ 19. Do you shop in a health food store? _____ What percent of the time?__________ 20. What percentage of the food you eat is organic? _____ %
Diet Hx: (Check all that apply)
Low Fat Vegetarian Generally Good Diet Diet Soda High Juice intake Crave Bacon & Lunch Meat
Low Carb Rotation Diet Gluten Free Diet Nutrasweet Love ice cream Love Donuts
High Carb Atkins Diet Allergy Free Diet High Caffeine Love milk High Sugar Intake
High Fat Diet Zone Diet Milk/Casein Free Diet Enteral Feed Restrict Salt Crave Non-edibles
Low Protein Ketogenic High Bread/Pasta Poor Food Choices Avoid Butter Avoid Eating
High Protein Always
Dieting
No Meat Diet High Beef Diet Avoid
Vegetables
Food Over consumption
EPD Diet Wheat Free Heavy Alcohol French Fries Avoid Salads Microwave used
Dietary Intake: (Circle Low (L), Medium (M), or High (H) intake For only those that pertain! Brand Names Used:
Sesame Oil L M H MCT Oil L M H Lard L M H Wesson
Safflower Oil L M H Soy Oil L M H Crisco L M H Best Foods
Flax Oil L M H Cottonseed Oil L M H Salad Dressing L M H Hellmann’s
Sunflower Oil L M H Peanut Oil L M H Mayonnaise L M H Miracle Whip
Walnut Oil L M H Corn Oil L M H Margarine L M H Kraft
Olive Oil L M H Mineral Oil L M H Butter L M H Mazola
Canola Oil L M H Mustard Oil L M H Coconut Butter L M H Other ___________________________
Daily Fluid Consumption:
Fluid Intake: _____ Cups of Water _____ Cups of Juice _____ Cups of Milk _____ Cans of Soda _____ Cups of Coffee/Tea ______
Apr 2019 www.ChelationMedicalCenter.com Page 11 of 11
DIETARY HISTORY FORM
PLEASE FILL OUT THE FOLLOWING WITH WHAT YOUR DIET TYPICALLY CONSISTS OF ON AN AVERAGE DAY.
PLEASE BE AS SPECIFIC (AND HONEST) AS POSSIBLE!
BREAKFAST: _________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SNACK: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
LUNCH: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SNACK: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
DINNER: ____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SNACK: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Are you willing to change your lifestyle/habits to improve your health? Yes No
What are your goals to improve your health? ______________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
***************************************************
Thank you for taking the time to complete this form. PLEASE BE SURE TO BRING THIS COMPLETED QUESTIONNAIRE TO YOUR APPOINTMENT
It is the beginning of your process of healing and good health!
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