Patient Registration

Patient Information
Name____________________________________________________________________________________________

Address_____________________________________________________________________________________________

City________________________________________State_________________________Zip_________________________

Phone: Home (_____) - _____-________ Office (_____) - _____-________ ext._______ Cell (_____) - _____-____________

Fax (_____) - ____-__________ E-mail____________________________________________________________________

EMERGENCY NOTIFICATION
In case of emergency, notify _____________________________________________________________________________

Address_____________________________________________________________________________________________

City_____________________________________________State__________________Zip___________________________

Phone: Home (_____) - _____-_________ Office (_____) - _____-_________ ext._____ Cell (_____) - _____-____________

Fax (_____)- ____-_________ E-mail __________________________________How related? ________________________

PERSONAL DATA
Sex:
 M  F Age:__________ Date of Birth _____________ Allergies_______________________________________

Height: Feet ____________ Inches ___________ Weight _______________________ Blood Type _____________________

Ancestry:  Caucasian   Oriental  African  Hispanic  Other _____________________________

Marital Status:  Married  Single  Widowed  Divorced         If married, how long? ________________________________

Children?  Yes   No How Many? Girls ________ Boys ________ Ages ______________________________________

Occupation _____________________________________________________ How many years? ______________________

OTHER
How did you hear about Health Consultations with Dr. Myatt? ___________________________________________________

How do you prefer to pay for your consultation (circle one) Visa/MC Check

Visa/MC # _____________________________________________ Expiration Date _________________________________

Authorization Signature ___________________________________ Today's Date __________________________________

Please make checks payable to: Dr. Dana Myatt. Payment by check must be received in advance.

Dr. Dana Myatt / P.O. Box 900 / Snowflake, AZ 85937 -- Phone: 1 - 800 - Dr. Myatt (367 - 9288)
www.DrMyattsWellnessClub.com

1994 - 2005 Dr. Myatt's Wellness Club


Page 2 of Patient Registration | When did you last have a complete physical exam?___________________

Diet: Record all food and drink, with appropriate amounts, for three (3) days. Attach an extra sheet if needed.

Day 1

Day 2

Day 3

Breakfast

 

Lunch

 

Dinner

 

Snacks

Beverages

Breakfast

 

Lunch

 

Dinner

 

Snacks

Beverages

Breakfast

 

Lunch

 

Dinner

 

Snacks

Beverages

Environment: Please check any of the following that you are exposed to.

 

Live or work around people who smoke.

 

Drink tap water.

 

Live or work in a city with polluted air.

 

Exposure to chemicals at work. (Please list)

Stress Index: Please rate each of the following as they currently apply to you.

 

Good

O.K.

Stressful (describe)

 

Good

O.K.

Stressful (describe)

Marriage / Relationship

 

 

Personal Health

 

 

Work

 

 

Health of Family

 

 

Children (relationship)

 

 

Other (please list)

 

 

Finances

 

 

 

 

 

Exercise: Check the exercises you do, with frequency and time.

Habits: Check which substances you use and describe how much.

Rest and Relaxation: Check the amount of each that you receive.

Exercise

x/week

time

 

Caffeine

 

hours

 

Aerobic

 

 

 

Tobacco

 

 

Sleep

/night

 

Weight training

 

 

 

Alcohol

 

 

Relaxation

/day

 

Flexibility

 

 

 

Soda Pop

 

 

Meditation

/day

 

Other (name)

 

 

 

Drugs (nonRx)

 

 

Hobbies

/day

 

 

 

 

 

Other

 

 

Other

/day

  1994 - 2005 Dr. Myatt's Wellness Club

Page 3 of Patient Registration

CURRENT HEALTH CONCERNS:

PHOTO

Please affix a recent photo of yourself in this space:

If photo is larger than this space, DO NOT CROP.

Affix with a paperclip, if available.

 

Please list below the Main Complaints you have, in ORDER OF IMPORTANCE to you:

When did this complaint begin?

1.

 

2.

 

3.

 

4.

 

5.

 

Personal Health Goals: Please describe what you hope to accomplish.
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________

FAMILY HISTORY: Check if your relatives have had any of the following:

Disease

Relationship to you

Disease

Relationship to you

 

Allergies

 

 

Heart Disease, Stroke

 

 

Asthma, Hay fever

 

 

High Blood Pressure

 

 

Birth Defects

 

 

High Cholesterol

 

 

Cancer

 

 

Kidney Disease

 

 

Diabetes

 

 

Mental Illness

 

PAST MEDICAL HISTORY: Please list all serious illnesses, injuries, and surgeries that you have had in the past.

Date

Illness/Injury/Surgery

Outcome

Date

Illness/Injury/Surgery

Outcome

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATIONS: List all prescription and non-prescription medications, nutritional supplements and herbs you are currently taking, including dose.
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

ALLERGIES: To medications, foods, or substances.
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________

1994 - 2005 Dr. Myatt's Wellness Club

 

Page 4 of Patient Registration:  INSTRUCTIONS: Check all medical conditions that you currently have or that you have had in the past one year, or that you are currently receiving treatment for. If you do not know an answer, leave it blank.

□ alopecia
□ ALS
□ Alzheimer's disease
□ anemia
□ angina
□ anxiety
□ appendicitis
□ arthritis, osteo
□ arthritis, rheumatoid
□ atherosclerosis
□ athlete's foot
□ asthma
□ attention deficit disorder
□ back pain
□ bladder infections
□ blood clots
□ boils
□ bone spurs
□ bronchitis
□ bruises, bruise easily
□ bulimia
□ bursitis
□ cancer
□ Candidiasis
□ canker sores
□ cardiac arrhythmia
□ cardiovascular disease
□ carpal tunnel syndrome
□ cataracts
□ celiac disease
□ cholesterol, elevated
□ chronic fatigue syndrome
□ chronic obstructive pulmonary disease (COPD)
□ cold sores
□ colitis
□ common cold, recurrent
□ congestive heart failure
□ constipation
□ Crohn's disease
□ Cushing's disease
□ cystitis
□ depression
□ dermatitis
□ dermatitis herpetiformis
□ diabetes, type I
□ diabetes, type II (adult onset)
□ diarrhea
□ diverticulitis
□ diverticulosis
□ ear infections
□ eczema

□ emphysema
□ endometriosis
□ epilepsy
□ Epstein-Barr syndrome
□ fibrocystic breast disease
□ fibromyalgia
□ fungal skin infection (tines)
□ fungus under nails
□ gallstones
□ gastritis
□ glaucoma
□ goiter
□ gonorrhea
□ gout
□ Goodpasture's disease
□ Grave's disease
□ Hashimoto's thyroiditis
□ hay fever
□ headaches
□ headaches, migraine
□ hearing problems
□ heart disease
□ hemorrhoids
□ hepatitis
□ hernia
□ herpes
□ high blood pressure (hypertension)
□ hives/urticaria
□ hyperthyroid (over active thyroid)
□ hypothyroid (under active thyroid)
□ hypoglycemia
□ idiopathic thrombocytopenic purpurea (ITP)
□ impotence
□ indigestion
□ infections
□ infertility
□ insomnia
□ iritis
□ irritable bowel syndrome
□ joint pain
□ kidney disease
□ kidney stones
□ liver disease
□ lupus (SLE)
□ Lyme disease
□ macular degeneration
□ memory loss
□ Meniere's disease
□ mononucleosis
□ Multiple Sclerosis (M.S.)
□ muscular dystrophy

□ myasthenia gravis
□ myelitis
□ neuralgia
□ neuritis
□ neuropathy
□ obesity
□ osteoarthritis
□ osteoporosis
□ panic attacks
□ parasites,intestinal
□ Parkinson's disease
□ pemphigus
□ periodontal disease
□ pernicious anemia
□ phlebitis
□ pneumonia
□ polymyalgia
□ premenstrual syndrome
□ prostate enlargement
□ prostatitis
□ psoriasis
□ rheumatic fever
□ rheumatoid arthritis
□ rosacea
□ scleroderma
□ seborrheic dermatitis
□ shingles (herpes zoster)
□ sinus infection
□ Sjogren's syndrome
□ stroke
□ tachycardia
□ tendonitis
□ thyrotoxicosis
□ tinnitus (ringing in the ears)
□ tuberculosis (TB)
□ tumors, benign
□ ulcer, duodenal
□ ulcer, gastric
□ ulcer, skin
□ uremia
□ urination problems (frequent urination)
□ vaginal infections
□ varicose veins
□ venereal disease
□ vitiligo
□ warts
□ weight gain
□ weight loss


List below any other medical diagnoses or conditions not listed elsewhere on this form.

_______________________________________________________________________________________________________

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© 1994 - 2005 Dr. Myatt's Wellness Club