IMS New Patient Questionaire

When completed, please print out and fax or mail in this form
along with the other materials.

date

name

street address

city

State (and country)

Telephone number home

Telephone number cell

Fax number

Social Security Number

Email address

Age

Date of Birth

Type of Work you do

Are you working now?

yes

Work address

Work phone

Work fax

Highest educational degree obtained

Name of person completing this form

Relationshp to patient

Name of spouse or significant other

Spouse's or significant other's contact number

Patient referred by whom

For what problem are you seeking assistance? (specific diagnoses{es} if possible)

When did the problem begin?

List the doctors you've seen for this problem with their specialties, addresses and phone numbers. First should be the "lead" physician, then others still involved. (If text goes out of the box, use an additional sheet to explain and attach when mailing)

Who is your primary care doctor?

Is your communication with your doctor(s) satisfactory? Explain

Has anyone done a medical literature search for your problem? Who and what?

What research and reading have you done on this problem?

What complementary or alternative medical therapies have you used or are using? Include self-care, group work, etc..

With what specific issues would you like my assistance?

Signature

Please write a brief narrative of your medical history for this problem on a separate sheet of paper. List treatments received and medications taken in the past and currently.

When completed, please print out and fax or mail in this form
along with the other materials.