Phone: Home (_____) – _____-________ Office (_____) – _____-________ ext._______
Cell (_____) – _____-____________
In case of emergency, notify:________________________________________________________________________
Phone: Home (_____) – _____-_________ Office (_____) – _____-_________ ext._____
Cell (_____) – _____-____________
E-mail __________________________________ How related? ________________________
Sex: Male Female
Age:__________Date of Birth _____________
Height: Feet ____________ Inches ___________ Weight _______________________
Blood Type _____________________
Caucasian Asian African Hispanic Other _____________________________
Married Single Widowed Divorced If married, how long? ________________________________
Yes No How Many? Girls ________ Boys ________ Ages ______________________________________
How many years? ______________________
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 _________________________________ CVV___________
Authorization Signature ___________________________________
Today’s Date __________________________________
Please make checks payable to: Dr. Dana Myatt. Payment by check must be received in advance.
Dr. Dana Myatt / 2535 N Beech Blvd, Camp Verde, AZ — Phone: 1 – 800 – Dr. Myatt (367 – 9288)
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.
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.
Marriage / Relationship: Good | O.K. | Stressful (describe)
Personal Health: Good | O.K. | Stressful (describe)
Work: Good | O.K. | Stressful (describe)
Health of Family: Good | O.K. | Stressful (describe)
Children (relationship): Good | O.K. | Stressful (describe)
Finances: Good | O.K. | Stressful (describe)
Other (please list)
Exercise: Check the exercises you do, with how often and how long.
Habits: Check which substances you use and describe how much.
Soda Pop, Energy Drinks, Sports Drinks, etc.
Rest and Relaxation: Check the amount of each that you receive.
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.
CURRENT HEALTH CONCERNS:
Please list below the Main Complaints you have, in ORDER OF IMPORTANCE to you and tell when this complaint began.
Personal Health Goals: Please describe what you hope to accomplish.
FAMILY HISTORY: Check if your relatives have had any of the following and their relationship to you:
Heart Disease, Stroke
Asthma, Hay fever
High Blood Pressure
PAST MEDICAL HISTORY: Please list all serious illnesses, injuries, and surgeries that you have had in the past with the date of the occurrence and the 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.
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.
? Alzheimer’s disease
? arthritis, osteo
? arthritis, rheumatoid
? athlete’s foot
? attention deficit disorder
? back pain
? bladder infections
? blood clots
? bone spurs
? bruises, bruise easily
? canker sores
? cardiac arrhythmia
? cardiovascular disease
? carpal tunnel syndrome
? celiac disease
? cholesterol, elevated
? chronic fatigue syndrome
? chronic obstructive pulmonary disease (COPD)
? cold sores
? common cold, recurrent
? congestive heart failure
? Crohn’s disease
? Cushing’s disease
? dermatitis herpetiformis
? diabetes, type I
? diabetes, type II (adult onset)
? ear infections
? eczema? emphysema
? Epstein-Barr syndrome
? fibrocystic breast disease
? fungal skin infection (tines)
? fungus under nails
? Goodpasture’s disease
? Grave’s disease
? Hashimoto’s thyroiditis
? hay fever
? headaches, migraine
? hearing problems
? heart disease
? high blood pressure (hypertension)
? hyperthyroid (over active thyroid)
? hypothyroid (under active thyroid)
? idiopathic thrombocytopenic purpurea (ITP)
? irritable bowel syndrome
? joint pain
? kidney disease
? kidney stones
? liver disease
? lupus (SLE)
? Lyme disease
? macular degeneration
? memory loss
? Meniere’s disease
? Multiple Sclerosis (M.S.)
? muscular dystrophy
? myasthenia gravis
? panic attacks
? Parkinson’s disease
? periodontal disease
? pernicious anemia
? premenstrual syndrome
? prostate enlargement
? rheumatic fever
? rheumatoid arthritis
? seborrheic dermatitis
? shingles (herpes zoster)
? sinus infection
? Sjogren’s syndrome
? tinnitus (ringing in the ears)
? tuberculosis (TB)
? tumors, benign
? ulcer, duodenal
? ulcer, gastric
? ulcer, skin
? urination problems (frequent urination)
? vaginal infections
? varicose veins
? venereal disease
? weight gain
? weight loss
List below any other medical diagnoses or conditions not listed elsewhere on this form.