Monroe Wellness Center - New Patient Intake Form

General Information

Full Name *

Preferred Name

Address *

City *

State *

Zip Code *

Home Phone

Work Phone

Cell Phone *

Email Address *

Age

Date of Birth *

Place of Birth

Gender *

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Partnership

Hand Dominance

Right Handed

Left Handed

Mixed Dominance

Occupation

Hours Per Week

Nature of Business

How did you hear about our clinic?

Genetic Background (check all that apply)

African American

Hispanic

Mediterranean

Asian

Native American

Caucasian

Northern European

Number of Children

Have you lived or traveled outside the United States?

Next of Kin or Emergency Contact *

Relationship *

Phone *

Chief Complaints/Concerns

Please list your chief symptoms in order of decreasing severity, starting with the worst one. Include onset, frequency, and severity.

Problem	Onset	Frequency	Severity

What diagnosis or explanation have been given to you?

When was the last time you felt well?

Did something trigger your change in health?

What makes you feel worse?

What makes you feel better?

Please list all types of physicians you have seen for your health conditions

Alternative Treatments Tried (check all that apply)

None

Chiropractic

Acupuncture

Massage

Yoga

Homeopathy

Nutritional Therapy

Meditation

Current Medications & Supplements

Current Medications (check all that apply)

Acid Blocking Drugs

Anti-anxiety

Antibiotics

Antidepressants

Blood Pressure

Cholesterol Lowering

Diabetic medications

Thyroid medication

Please list all medications with dosages

Please list all vitamins and supplements

Allergies (medications, supplements, foods)

Nutrition & Lifestyle History

Do you currently follow a special diet?

Yes

No

If yes, which diet? (check all that apply)

Low fat

High protein

Vegetarian

Vegan

Gluten restricted

Low carb

Diabetic

Any specific food restrictions?

Height (feet/inches)

Current Weight (lbs)

Desired Weight (lbs)

Do you purchase organic foods?

Yes

No

Sometimes

What is the most important thing you should change about your diet to improve your health?

Exercise & Physical Activity

Current Exercise Program

Rate your motivation for including exercise in your life

Low

Medium

High

List any problems that limit your physical activity

Tobacco & Alcohol Use

Do you currently use tobacco?

Yes

No

If yes, please provide details

Alcohol consumption per week

None

1-3 drinks

4-6 drinks

7-10 drinks

>10 drinks

Sleep & Stress

Average hours of sleep per night

<6 hours

6-8 hours

8-10 hours

>10 hours

Do you have trouble falling asleep?

Yes

No

Do you feel rested upon awakening?

Yes

No

Do you feel you have an excessive amount of stress in your life?

Yes

No

Daily stressors - Rate on scale of 1-10 (1=not stressful, 10=very stressful)

Do you practice meditation or relaxation techniques?

Establishing Health Goals

Personal Message from Dr. Wallace:

In this practice, we choose to accept only the most motivated patients into our program. After many years in private practice, I have seen many patients achieve significant improvement while others have become frustrated and failed in their attempt to get well.

We get great results with those who do what it takes to get well. If you are not willing to change things, then you can expect to get what you already have...poor health.

What do you hope to achieve in your visit with us?

If you had a magic wand and could erase three problems, what would they be?

Have you made the decision to change? To do what it takes to get well?

Yes

No

Readiness Assessment

Rate on a scale of 5 (very willing) to 1 (not willing):

In order to improve your health, how willing are you to:

Significantly modify your diet

5 4 3 2 1

Take several nutritional supplements each day

5 4 3 2 1

Modify your lifestyle (work demands, sleep habits, etc.)

5 4 3 2 1

Engage in regular exercise

5 4 3 2 1

Practice relaxation techniques

5 4 3 2 1

Have periodic lab tests to assess progress

5 4 3 2 1

Rate on a scale of 5 (very confident) to 1 (not confident at all):

How confident are you of your ability to organize and follow through on the above health-related activities?

5 4 3 2 1

If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity?

Rate on a scale of 5 (very supportive) to 1 (not supportive at all):

How supportive do you think the people in your household will be to your implementing these changes?

5 4 3 2 1

Additional Information

Is there anything else you'd like Dr. Wallace to know about your health history, concerns, or goals?

Consent & Signature

I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that this information will be used to help determine the most appropriate care for my health concerns.

I certify that all information provided is accurate and complete *

Full Name (as signature) *

Date *

Introductory Patient Information

General Information

Chief Complaints/Concerns

Current Medications & Supplements

Nutrition & Lifestyle History

Exercise & Physical Activity

Tobacco & Alcohol Use

Sleep & Stress

Establishing Health Goals

Readiness Assessment

Additional Information

Consent & Signature

✓ Thank You for Completing Your Patient Intake Form!

Contact Us

Contact Us