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  FAge:__________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   NoHow 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/MCCheck

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 | 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 – 2005Dr. 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 :  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.

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________
© 1994 – 2005 Dr. Myatt’s Wellness Club