Welcome. Enclosed is the New Patient Packet you have requested. Please fill out the Questionnaires and Medical Information Forms and return it to our office. New patients cannot be seen without this information. Upon receipt of the Packet, we will contact you to make your first appointment. Complete these forms as fully as you can, even if you are not sure of all the answers. The Diagnostic Tests and Treatments Forms are especially important as they will guide us in your treatment planning process. If you have a single, straightforward health problem you may skip the questions that are not relevant. However, most people's problems are inter-related and relatively complex, so a full history is important. If possible, please send or bring copies of previous Laboratory or X-Ray Reports, especially if the results were abnormal. (Usually, the reports are enough. We do not need the actual X-Ray films.) Because of the time set aside for your Initial Visit and the time spent to review your case in advance, we require a $150.00 Non-Refundable Deposit to hold your appointment (attach payment to your completed Patient Packet and return it to our office). Your deposit will be deducted from your Initial Visit fee. New patient visits are at least 1½ to 2 hours. The fee for an Initial Visit is $690.00 with Dr. Podell and $550.00 with Edwina S. King, PhD, APN (Advanced Practice Nurse). Payment is required at the time of service. This includes a comprehensive review of your medical history and a detailed explanation of treatment options and recommendations. The typical patient requires a comprehensive initial visit, then follow up visits, ranging from $100.00 to $200.00. We do not participate with any Health Insurance Company except Medicare. Dr. Podell is no longer accepting new Medicare patients. We will provide you with a receipt that you can submit to your insurance plan for reimbursement. Most patients are eligible for reimbursement under the “Out Of Network” provisions of their policy. We now have two locations in New Jersey: Springfield and New Brunswick area (105 Morris Avenue, Suite 200, Springfield, NJ 07081, Tel: 973-218-9191, Fax: 793-218-1199) and (53 Kossuth Street, Somerset, NJ 08873, Tel: 732-565-9224). We wish you well in your process of healing and look forward to working with you. Yours truly, Edwina S. King, PhD, APN

Director Behavioral Medicine &
Clinical Research

Richard N. Podell, M.D., M.P.H.
Collaborating Physician
Clinical Professor, Dept. of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
Beverly Licatta, R.N.-Nurse Educator
Patient Information
Marital Status: Married  Single  Widowed  Divorced  Separated  Relationship to Insured: Self  Spouse  Child  Other  Health Insurance Information (Primary)
Insured’s Relationship to Patient: Self Health Insurance Information (Secondary)
Insured’s Relationship to Patient: Self  Spouse  Child  Other  Financial Responsibility (Person Financially Responsible for Patient Named Above)

I understand that Richard N. Podell, MD, does not participate with any health insurance and that payment is due at the time services are rendered. I agree to these payment terms and guarantee payment to Richard N. Podell, MD, for any services provided to the patient named above. Medicare
I authorize the release of any information necessary to process medical claims for the patient named above and authorize that payment of Medicare
benefits for these claims be made to our office. Also, I agree to promptly pay for any services not covered by Medicare and or determined by Medicare to be
my responsibility (i.e., Deductibles, Co-payments dictated by Medicare such as 20% of the allowable fee for Medical Services and 50% of the allowable fee
for Psychological Services when deemed “Reasonable and Necessary”, and any charges for Services and/or Laboratory Tests not
covered or deemed “Not Reasonable and Necessary”).
Primary Care Physician:
How did you hear about us? Doctor  Radio  Newspaper  Friend  Other
Name of Pharmacy:
Pharmacy Phone:
Drug Allergies: No  Yes  If yes, list names:________________________ Prescription Plan? Yes  No  Practitioner Use Only PATIENT HEALTH HISTORY QUESTIONNAIRE
Your Name____________________________________ Fax: _________________ E-mail:_______________ Address:_____________________________________________________________ City: _________________________ State:______ Zip:______________________
Referred By:______________________________________
City:_________________________State:_____ Zip:_______
Tel: _________________________


1) My Most Important Problem Is:

2) What have other doctors thought was the main cause or diagnosis?

3) Do you agree? Yes, largely ____ Yes, partly ____ No____
What do you think is likely to be the main problem or diagnosis (or aspect of your problem that might have been overlooked)?
4) Please comment on your most important current problems.

For the severity column, use 10 as severe and 0 as okay.
Rate as many as are important, especial y if their severity score is 5 or more. SEVERITY (0-10) ABOUT when did MARK if
With joint swelling HEAD/NECK PAIN SLEEP PROBLEMS DEPRESSION MEMORY PROBLEMS WEIGHT GAIN WEIGHT LOSS DIZZINESS OR al ergy problems Food al ergy or Intolerance Yeast (Candida) problem Nutritional Problem Specify:_______________ Fever Enlarged lymph glands Others:________________ 5) Describe the time and circumstances when the main problem(s) first appeared
and/or worsened. (Feel free to type or write extended answers on a separate
6) Are you currently working or in school?______ What do you do?_____________

7) Do your symptoms limit your effectiveness?_____________________________

8) Current Medicines (include non-prescription and hormones)_________________
Current vitamins/herbs______________________________________________
9) Medicine Allergies__________________________________________________

10) Medicines Not Tolerated_____________________________________________

11) Are you concerned about possible side-affects from any of your medicines?____
Which ones?______________________________________________________
12) Did any of your important symptoms worsen within a few weeks of starting or
changing the dose of a medicine?______________________________________
13) Have you recently used marijuana, cocaine, LSD or other street drugs?________
Have you ever had a substance or alcohol problem?_______________________
14) State as specifically as you can which problem or kind of help you most
want to focus on now AND what you would like to achieve through our

Do you have specific approaches or treatments in mind that you think

might be helpful or that you want to be especially sure we consider? If
so, please state:____________________________________________

15) If you have ever been hospitalized or had an operation indicate why and
approximate dates:_________________________________________________
16) Indicate how the following factors affect your major symptoms by marking (B) if
they make you feel better, (W) worse, or (?) if you are not sure. If not
relevant, leave blank. State which symptom(s) are affected. Exercise__________ Sleep__________ Food/Eating___________________ Alcohol __________ Caffeine________ Salt_________________________ Stress____________ Season_________ Sunlight______________________ Time of Day_______ Heat___________ Cold_________________________ Humidity_________ Barometric Pressure_____________________________ Other____________________________________________________________ SECTION II: SPECIFIC SYMPTOM AREAS & LIFE-STYLE ISSUES
X if the question applies to you. Leave blank if it does not.

New onset, persistent or relapsing, debilitating fatigue_____ No previous history of similar symptoms_____ Does not resolve with bed rest_____ Persists at least 6 months_____ Substantial reduction of previous activity_____ Severe symptoms began: Suddenly_____ Gradually_____ Not sure_____ CHRONIC FATIGUE SYNDROME ADDITIONAL CRITERIA: "Official" diagnosis
requires 4 or more of the following being present for more than six months: • Impaired memory or concentration • Frequent sore throat • Painful/tender nodes esp. neck or armpit • Muscle pain (Myalgia) o With marked weakness o Without marked weakness • New or different headaches • Unrefreshing sleep (Includes sleeping too much or too little) • Typical y feel worse after physical activity • New or different headaches • Unrefreshing sleep (Includes sleeping too much or too little • Typically feel worse after physical activity o Immediately after o After several hours o Both early and late o Not sure o Do not exercise
Other Potentially Related Symptoms
Light-headed, Faint, Dizzy, Vertigo, Off-Balance_____ Worse when standing_____ Irritable Bowel: Gas_____ Constipation_____ Diarrhea_____ Blood in stool_____ Anxiety_____ Panic_____ Breathless or disordered breathing_____ Alcohol problem in your history or in family_____ Vaginal discharge_____ Comments:________________________________________________________

Your age when muscle pain began_____
Onset was: Gradual_____ Sudden_____ Describe:_________________________ Current status: Severe_____ Moderate_____ Mild_____ Do joints swell_____ If yes, which?_____________________________________
Areas Involved (X for mild, XX for moderate, XXX for severe)
Head_____ Side(s) of head or temple(s)_____ Jaw_____ Neck_____ Right upper back_____ Left upper back_____ Right shoulder_____ Left shoulder_____ Mid- back_____ Chest (worsens with exertion)_____ Chest (doesn't worsen with exertion)_____ Is pain worse when you breathe?____ Low back/spine_____ Right hip/buttock_____ Left hip/ buttock_____ Right upper leg_____ Left upper leg_____ Does pain radiate down leg?_____ Right knee_____ Left knee_____ Right calf_____ Left calf_____ Right foot/ankle_____ Left foot/ankle_____ Right arm_____ Left arm_____ Right hand/wrist_____ Left hand/wrist_____ Other areas of pain:_________________________________________________ Are your muscles often very sore to the touch?_____ If so, where, mainly?________________________________________________ Does moderate exercise worsen pain?_____ Reduce pain?_____ Have no Is your pain much worse at night?______________________________________ Do you often feel stiff in the morning?___________________________________ Do you often have night sweats?_______________________________________ Have you had x-rays of any of the painful areas?__________________________ What did they show?_________________________________________________
Is there a Personal (P) or Family history (F) of:
Psoriasis_____ Crohn's Disease or Ulcerative Colitis_____ Rheumatoid Arthritis_____ Spinal Arthritis_____ Ankylosing Spondylitis_____ Sjoegren's
Which medicines help your muscle aches?
X for a little, XX for moderate, XXX for very helpful, NC if No Change, W if
it made you worse. Leave blank if you haven't tried it. Aspirin or Ibuprofen_____ Celebrex or Vioxx (Cox-2 Anti-Inflammatories) _____ Tylenol_____ Codeine_____ Prednisone/Steroid_____ Percodan/Percoset_____ Ultram_____ Other__________________________________________________
Have the following lab tests been abnormal? (leave blank if not done)
Sed Rate_____ CRP_____ Lyme Test_____ ANA_____ Rheumatoid Factor_____ Latex_____ CPK_____ HLA B-27_____ SSA/SSO_____


Heart Attack, Stroke or Arterial Disease of the leg before age 60_____ High Blood Pressure_____ High Cholesterol/Triglycerides_____ Diabetes_____
Major Depression_____ Manic Depressive Illness_____ Major Anxiety_____ Panic Anxiety_____ Alcoholism or Drug Abuse_____ Suicide Attempt or Success_____ Attention Deficit_____ Obsessive-Compulsive Disorder_____ Breast Cancer_____ Colon or Rectal Cancer_____ Melanoma/Skin Cancer_____ Prostate Cancer_____ Stomach Cancer_____ Other______________________

I can comfortably walk:
<1/4 Mile_____ 1/4 Mile_____ 1/2 Mile_____ 1 Mile_____ >1 Mile_____ If you cannot comfortably walk one mile what are the main limiting factor(s)? Weakness_____ Short of breath_____ Joint pain_____ Muscle pain_____ Chest Haven't tried to exercise much, so I'm not sure_____ Comment__________________________________________________________ During the last few months I have typical y exercised: _____times a week for Intensity: Gentle_____ Moderate_____ Vigorous_____ Usual type of exercise________________________________________________ If you don't exercise, state why________________________________________ For current exercise my preferred form would be: Walking_____ Treadmill_____ Swimming_____ Indoor Bike_____ Other_____________________________________________________________ When I exercise I usually feel: better_____ the same_____ immediately worse but recover quickly_____ immediately worse but take many hours to recover_____ immediately not bad but get worse hours later or the next Exercise causes: abnormal chest pain or pressure__________ wheezing_______ mental cloudiness_____ other unusual symptoms__________________________

Do you ever fall asleep inappropriately, e.g., at work/school_____ while driving_____ with other people_____ watching T.V. _____? Sleep schedule: About what time do you usually go to bed?__________________ About what time do you usually actually fall asleep?________________________ About what time do you get up in the morning?___________________________ Subtracting interruptions, how many hours do you actually sleep?_____________ Do you usually need an alarm clock? _____ Do you usual y sleep more than 45 minutes longer on weekends or When you wake in the morning do you usually feel you have rested well? _____ Is initially falling asleep often a problem? _____ Do you wake too often during the night? _____ Do you take naps? _____ Do these refresh you? _____ Are you sleeping much less (say 45 minutes or more) than you used to, e.g., when you were last feeling wel ? _____ Do you or did you take sleeping aides more than once a week?_____ If yes, please state the name(s) and whether they Helped (H), made No Change (NC) or
made you Worse (W)________________________________________________

Is there someone who could observe you when you are asleep for 30 minutes or more? _____ If so, please ask them to observe your breathing for 30 minutes while Look for struggling for breath, heavy snoring, pauses in breathing of 10 seconds or more. Also look for frequent fine or gross muscle twitching or jerks. (This is important. Sleep disorders are easily overlooked.) Sleep Apnea: Do you snore? _____ Toss and turn a lot? _____ Cease breathing, snort, or struggle for breathe while you are asleep? _____ Have you had someone observe you? Yes_____ No_____ Not sure_____ Periodic Leg Movement: Has anyone you shared a bed with observed that your muscles often twitch or limbs jerk? _____ (Note: a quick spasm while falling asleep is okay.) Do you toss and turn a lot/Is the bedding a mess? _____ Do you sleep quietly, hardly moving at all? _____ Do you often wake with a Headache? _____ Muscle aches? _____
How do you rate your diet: Excellent_____ Good_____ Fair_____ Poor_____ Comments:________________________________________________________ About how many times in an average week do you eat: Green leafy vegetables (excluding lettuce) _____ Yel ow vegetables (carrot/squash/sweet potato) _____ Berries_____ Fruit_____ Fish_____ Yogurt_____ Milk/cheese_____ Ice cream_____ Chocolate_____ Beef/pork_____ Chicken/turkey_____ Salad dressing or vegetable oil_____ Soy_____ How many times a week do you: Eat at home_____ In a restaurant_____ Skip breakfast_____ Skip lunch_____ Skip dinner_____ Do you consciously try to reduce your intake of: Sugars_____ Other carbohydrates_____ Artificial sweeteners_____ Caffeine_____ Alcohol_____ Protein_____ Why?_______________________________________ Do you restrict your fat intake: Mildly_____ Moderately_____ Severely_____ Not Do the following foods often help you feel Better (B) or Worse (W)? Sugar_____ Starch_____ Alcohol_____ Caffeine_____ Milk products_____ Fatty foods_____ Organic food_____ Yeast/mold_____ Additives_____ Wheat/gluten_____ Chocolate_____ Garlic/onion_____ Spices_____ Deli meats_____ MSG_____ Artificial sweeteners_____ Are there specific foods you feel you “almost can't live without?” If so, which? Do you avoid certain foods because you suspect you are allergic or do not tolerate them? _____ Which?________________________________________________ Have you had food allergy testing? _____ What kind of test? _____ What were the results?_______________________________________________ Are these results general y consistent with your experience?_________________
How many cups/glasses per day do you drink of: Coffee_____ Decaff coffee_____ Tea_____ Herbal tea_____ Cola drinks_____ If you drink caffeinated drinks regularly, have you abstained completely from caffeine for two days or more since you have been il ?_____ If so, what happened?_________________________________________________________ If you omitted caffeine, do you think you would likely develop a headache_____ Muscle ache_____ Severe fatigue_____ Mental cloudiness_____? Indicate how many portions a day you typically have: Whiskey_____ Wine_____ Beer_____ Other alcohol_______________________ Do you or anyone else suspect you might have a drinking problem?____________
Do you suspect you might have "Hypoglycemia?" __________________________ Do you often have increased symptoms 3 or 4 hours after eating?_____________ Or if your meal is late?______ Or if you eat too much sugar or starch? ________ What are your symptoms?____________________________________________ Do you have increased symptoms within one hour of eating?_________________ Which symptoms?___________________________________________________ Do you usually have snacks?______ When?______ Is snacking helpful?_______ CANDIDA (YEAST) SYNDROME (controversial and unproved) Do
you often have vaginal yeast infections? _____ Do you often have intestinal gas, bloating, diarrhea or constipation? _____ Do your symptoms worsen when you eat a high sugar or high carbohydrate diet? _____ Do they improve with reducing sugar, bread, and/or starch? _____ Do symptoms worsen with alcohol? _____ Have you often taken antibiotics?_____ Estrogen hormones or birth control pills? _____ Cortisone/Prednisone? _____ Have you or a health care professional suspected that you have a yeast or Candida problem? _____ If so, when, by whom and what test?_______________ Have you tried at least two months of a Candida yeast diet with or without Did it help_____ Cause no change_____ Make you worse_____
Do you often have diarrhea (multiple or loose stools) _____ Constipation_____ Abdominal gas or bloating_____? Do you ever have blood in your stool_____ Very dark tarry stool_____? What factors do you suspect of contributing to these symptoms?________________________________________________________ Do you often take extra fiber or fiber pil s_____ Stool softeners_____ Laxatives_____? If yes, do they usually seem to help_____ Cause no Do you often have excess acid symptoms, gastritis, esophagitis, heartburn, or Have you ever been tested for Helicobacter bacteria (H. Pylorus)? _____ Was the test positive? _____ Were you treated?___________________________ Have you ever had intestinal parasites, worms, ameba, giardia or other intestinal infection?__________________________________________________________
Noise Heat/humidity Lights Odors or Smel s Computers Others being ill Tobacco/Indoor Pollution Occupational Chemicals Cold Repetitive Tasks Posture How old is your home?__________ Is it often damp________ Moldy________ Dry________ Very dusty________ Pets________? Do you have air-conditioning______ Central A/C______ Bedroom A/C______? In your bedroom do you have: Carpets_____ Area carpet_____ Wall to wal carpet_____ A central air filter_____ Portable filters_____?

X if the question applies to you. Leave blank if it does not.



Have you had a sinus infection in the last 4 months or more than 2 sinus infections in the last year?_____ Do you have chronic nasal stuffiness?_________ Post Do you often have yellow or green mucus from you nose, lungs or throat?______ Do you often have sinus-type pressure over, under or between your eyes?______ Do you have a sore throat more than once every 8 weeks?______ Have you ever had a sinus CT scan or x-ray?______ Results?____________________________ Do you seem to react with allergies?______ What kind? ____________________ Are you exposed to high doses of unusual chemicals as well as indoor or outdoor air pollutants?______________________________________________________ Is your work or home environment poorly ventilated?_______ Is it exceptionally dry?______ Humid?______ Did any changes in your work or household environment precede the worsening of your health?_______________________________________________________ Do you develop symptoms when exposed to environmental chemicals or odors?____________________________________________________________
Do you often Wheeze ____ Cough ____ Feel chest tightness____ Does exercise make it worse?____ Does cold air?____ Do you often cough mucus from your lungs?____ Have you ever had a lung function test or been told you have Asthma, Emphysema or any other Lung Disease?______ Have you had a Chest X-Ray within the last 5 years?_____ When?_____ Results?_________ Do you currently smoke tobacco?_____ Have you smoked regularly within the last
Do you often have burning or pain when you pass your urine?_____ Do you have difficulty starting urination?____ Slow urine flow?_____ Do you ever spill urine accidentally (incontinence)?____ Do you have diabetes or a blood sugar problem?____ Women: Do you have more than one urine infection per year?_____ Men: Have you ever had urine infections?_____ Comments:_______________________________________________
Lyme Disease:
Have you ever had or been told that you had Lyme Disease? Yes___ No___ Not sure___ Have you had a bull's eye type rash that grew over several weeks or months before disappearing?_____ Have you ever had an abrupt weakness on one or both sides of your face (Bel 's Palsy)?____ Are you often exposed to Comments:________________________________________________________
Fever and Other Infections
Do you often feel warm?_____ Have chil s?_____ When you feel warm what is your actual temperature range?_____ Do you have any AIDS risk factors or abnormal tests?______________ Have you had close exposure to someone with tuberculosis, a positive skin test or signs


Do important symptoms get markedly worse in the week or two before your period and improve substantially once you have had your period?_____________ If yes, which symptoms?_____________________________________________ Do you have menstrual cramps or related symptoms that are severe enough to disturb your feeling of well-being or daily function?_____ Do you have vaginal bleeding other than at your period?_____ Are you taking contraceptives or other measures to avoid pregnancy?
Do you have mood swings____ Hot flashes_____ Night sweats_____?
Are hot flashes or night sweats very bothersome?_____ Have you had a hysterectomy?_____ Which symptoms, if any, improved or worsened after menopause?_______________________________________________________ Have you ever been told that your thyroid is abnormal?____ Ever on thyroid medicines?____ Do you have any swelling in the lower neck?____ Did you ever receive x-ray treatments to the neck?____ Family History of Thyroid disease?____ Are you intolerant of cold?____ Is your auxiliary temperature <97 degrees before you get out of bed?____ Do you feel hyper?____ Intolerant of heat?____ Rapid heart rate?____ Weight gain or loss?____ Sweats?____ Do you have any discharge from your nipples?______ Has anyone told you that you have low adrenals?______ Do you have excess hair growth on face or body?______

Do you often feel light-headed or have a rapid heart rate when you stand up
quickly?_____ When you stand still for awhile?_____ Orthostatic symptoms: Do you tend to have low blood pressure?_____ High blood pressure?_____ Do you have chest tightness, pressure or pain, or any distress or abnormality when you exert yourself or exercise?_____ Have you ever had a heart attack or angina?_____ Heart catheterization?_____ Angioplasty or heart surgery?_____ Have you ever had a stroke or near-stroke (TIA)?_____ Do you often have calf or leg pain About what level is your total cholesterol?_____ LDL?_____ HDL?_____ Have you ever had an EKG?_____ Exercise Stress test?_____ ECHO cardiogram?_____ Were any results abnormal?______________________ Do you have Mitral Valve Prolapse?_____ Other murmurs or heart valve problems?_____ Frequent extra or skipped heart beats/palpitations?_____ Need antibiotics before seeing a dentist?_____

Do you have a headache more than once weekly?_____ Severe enough to reduce
activity_____ On one side of head at a time_____ Preceded by "aura"_____ With nausea_____ (These suggest migraine) Related to: Stress_____ Posture/position_____ Nasal sinus congestion_____ Muscle tension_____ Medicines_____ Caffeine_____ Food_____ Do headaches wake you from sleep?_____ Worse on waking in AM_____ Pain in jaw_____ Grind teeth at night_____ Jaw locks or can't open widely_____ How often do you take headache medicine?___________________ Do you drink caffeine or take pills with caffeine daily?______ SECTION IV: NEUROCHEMICAL BALANCE & EMOTIONAL HEALTH
X if the question applies to you. Leave blank if it does not.
During the last three months have you been under severe emotional stress? Yes_____ No_____ Not sure_____ If yes, what do you think are the most important contributors?_________________________________________________ Are you under the care of a therapist? Who and why? Is it helping? Who are the individuals (and ages) that live with you?_________________________ What is the attitude of those closest to you regarding you and your il ness? Describe your attitude toward your il ness. (mark along scale) Hopeless/Pessimistic 0 _______________________________ 10 Hopeful/Optimistic

Has there been increased stress in your life?_____ Why?___________________
Do you feel nervous, jittery or anxious more often than you like?______________ Why?_____________________________________________________________
Do you often have these symptoms? (Circle symptoms that apply):

Physical Muscle tension or activity:
Jumpiness, Trembling, Muscle-Tightness,
Heaviness or Aching, Fidgeting, Restless, Easy to Startle
Symptoms of over-activation: Sweating, Heart-Pounding, Cold or Clammy
Hands, Dry Mouth, Light-Headed, Numbness, Tingling, Hot or Cold Spells, Frequent Urination, Diarrhea, Stomach Discomfort, Lump in Throat, Flushing, Fears: Worry, Fearful expectations about self or family, Fear of losing control or
having an accident, Specific phobias or fears such as: Being Alone, Open Spaces, Closed Spaces, Automobiles, Bridges, Heights Hyper alertness: To threats or troubles in the environment, To symptoms or
functions of your body, On-edge, Irritable, Impatient, Difficulty Sleeping Have you ever had a "panic attack?"________ Do you have them more than once a month?_______ Do you spend much time or energy anticipating or worrying about your next episode of symptoms or illness?________________________________________

Do you often feel:
Loss of enthusiasm or interest in your usual activities____ Depressed/sad/blue____ Loss of appetite_____ Increased appetite____ Weight loss____ Weight gain_____ Life seems not worth living____ Have you ever seriously considered suicide?____ Have you thought of suicide recently?____ Explain:_______________________________________________ Have there been important reverses in personal/family/finance?______________ Increased use of alcohol, drugs or caffeine_____ Increased use of mood altering medicines_____ Have you ever been seriously depressed____ Have you ever taken medicines for depression?_____ Which ones?______________________ Did they help?_____ Is depression or fatigue usually worse in the winter and better in the spring or on vacations to warm climates?_____________________________________________

Are there periods during which you are abnormal y super-productive or
Has anyone ever suggested that you might be "hypomanic" or have manic- depressive or bipolar depression?_______________________________________

Has there been major physical or emotional trauma any time in your life?_______
For example: Loss of a loved one____ Divorce____ Physical abuse/violence____ Sexual abuse (e.g. rape or incest)____ A serious accident or illness___________ Do disturbing thoughts, dreams, or images related to past events recur frequently?________________________________________________________

Do thoughts often intrude that you cannot keep out?_____ Do you feel
compulsive impulses to perform hand-washing, counting, throat-clearing, touching or phrases, noises or other acts or actions?_____ Do you have recurring tics or

Often lightheaded or dizzy_____ Numbness/ tingling_____ Spasm or cramps of
hands or forearms_____ Feel short of breath_____ Frequent sighing_____ A sense that you can't take a full breath in_____ Short of breath with mild exertion_____ Feel "spacey"_____

Have you had since childhood or teenage years great difficulty focusing or
Have you had an unusual y short attention span?_____ Have you or others thought that you might be "hyperactive" or have Attention Have you ever been treated with or benefited from Ritalin, Dexedrine or stimulant

Did your problem begin or increase markedly after a major illness, stress or
Do direct or indirect reminders of difficult or traumatic episodes or periods tend to Once your symptoms begin, do you become more frightened, upset or tend to Do you spend time or energy anticipating or worrying about your next episode of Do you have a powerful or vividly imaginative mind or creativity in art, music, Can you produce interesting or detailed fantasies, daydreams or changes of mood with

Illogical thoughts_____ Hallucinations_____ History of psychosis or
schizophrenia_____ Paranoid thoughts_____ Erratic or highly variable

Do you usually feel impatient, rushed or time pressured?_____ Are you often


Craving for sugar, or starch____ Depression worse in winter_____ PMS_____
Decreased sweating_____ Intolerant of heat_____ Low grade fever_____ Feel chronically stressed_____ Often depressed_____ Are you now or have you recently been in counseling or therapy?____ If Name_______________________________ Tel:_________________________ Address:__________________________________________________________ REVIEW OF CURRENT SYMPTOMS
for Mild  for Moderate  for Severe Constitutional:
“Brain Fog”/Difficulty Concentrating Mood Swings Lymph Nodes:
G.U. & Hormonal (Female):
G.U. (Male):

Please complete as fully as you can.

Instructions for completing the form:
Mark (H) if a treatment helped you, mark
(W) if it made you worse, mark (NC) if there was no change, or mark (?) if you are not
sure. If you have not tried a treatment leave that space blank.
Nutritional Treatments
Hypoglycemia Diet
Herbal Therapies
Mind/Body Therapies
Body Work
Hormonal Treatments
Blood Pressure Raising Tactics
Jobst Stockings
Neurochemical Medicines
Muscle Relaxants
Sleep Medicines
Anti-Anxiety Medicines
Nerve/Pain Stabilizing Medicines
Stimulant-Like Medicines
Pain Medicines

Please complete this form and attach test results/reports or bring them with

you at your initial appointment.
Instructions for completing the form: For normal mark (N), for abnormal mark
(A), for not sure mark (?). If not done please leave blank. Also, estimate the year in which
the testing was most recently done, e.g., 1999, 2002, etc.
Basic Tests

Source: http://www.drking.org/newpatient.pdf

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© 2011 Universities Federation for Animal Welfare The Old School, Brewhouse Hill, Wheathampstead, Do farmers and scientists differ in their understanding and assessment of farm animal welfare? School of Agriculture, Food and Rural Development, Newcastle University, Newcastle upon Tyne NE1 7RU, UK* Contact for correspondence and requests for reprints: [email protected] Abst

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