New Patient Form

Thursday, May 17, 2012

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Our patient coordinator will be happy to answer your questions and discuss your treatment options!

Call us: 1-888-544-5993
International Patients
(outside the U.S.A.),
Please Call: (941) 922-4503

Fax: (941) 921-3536

WEBSITE TERMS OF USE AND CONDITIONS

Your name *
Telephone *
E-mail *
City
State *
Country *
Occupation
Age
Sex	Male Female
Status	Single Married Divorced Widow(er)
What is your diagnosis?
When was your diagnosis made?
List your symptoms and complaints
Treatments received and their dates (e.g. chemotherapy, radiation, surgery, othe
Do you suffer from pain?	Yes No
List the names and amounts of the pain medications you take, if any:
Do your bowels move regularly?	Yes No
Has there been any recent changes in your bowel movements or stools?	Yes No
Do you exercise regularly?	Yes No
What type of exercise and how often?
Do you sleep well?	Yes No
Do you sleep an average of 8 hours?	Yes No
Is your diet well balanced?	Yes No
Has there been any recent changes in your appetite or eating habits?	Yes No
Do you drink alcoholic beverages?	Never Rarely Moderate Daily
Cigarettes - how many packs per day?
Cigars	Yes No
Pipe	Yes No
Chewing	Yes No
Snuff	Yes No
Recreational drugs	Never Occasionally Frequently Daily
Laxatives	Never Occasionally Frequently Daily
Vitamins	Never Occasionally Frequently Daily
Sedatives (e.g. sleeping pills)	Never Occasionally Frequently Daily
Tranquilizers	Never Occasionally Frequently Daily
Aspirin	Never Occasionally Frequently Daily
Steroids	Never Occasionally Frequently Daily
Thyroid medications	Never Occasionally Frequently Daily
Appetite suppressants	Never Occasionally Frequently Daily
Have you ever been treated for drug habits?	Yes No
Do you take insulin or pills for diabetes?	Yes No
Hormone replacement therapy	Yes No
How many hours a day do you work indoors?
How many hours a day do you work outdoors?
WOMEN ONLY (MENSTRUAL HISTORY)
Age of onset
Is your menstrual cycle regular?	Yes No
Usual duration in days
How is your cycle?	Heavy Moderate Light
Pain or cramps?	Yes No
Date of last period
How many children born alive?
How many children born premature?
How many cesarean sections?
How many miscarriages?
Did you have any complications with any pregnacy?	Yes No

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