Surveypoint

Q1

The only cost I will incur is the cost of any initial screening tests that I choose to undergo, which may include:

Q2

Name:*

Q3

Phone:*

Q4

Patient*

Q5

Signature*

Q7

Name*

Q8

Age

Q9

Sex:*

Male|Female

NULL

Q10

DOB*

Q12

Address

Address*

Q13

Address*

Q14

City

Address*

Q15

State

Address*

Q16

Zip

Address*

Q17

Cel Phone

Q18

e mail:*

Q19

Height:*

Q20

Weight:*

Q21

How Did You Hear About Us?*

Q22

Employer*

Q23

Occupation*

Q24

Length of Employment*

Q25

Main Problem(s):*

Q26

In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else. In your own words and your own opinion what do you think the real problem is*

Q27

When were you diagnosed with Type II diabetes:*

Q28

What diagnostic tools were used to achieve your diagnosis:*

Q29

What are the three things your condition has caused you to miss most:*

Q30

Severity of problem (select):*

Minimal (annoying but causing no limitation)

Slight (tolerable but causing a little limitation)

Moderate (sometimes tolerable but definitely causing limitation)

Severe (causing significant limitation)

Extreme (causing near constant limitation)

Q31

Symptoms(list all):*

Q32

What relieves your symptoms or causes them to return:*

Q33

Describe the first time you remember having symptoms:*

Q34

What is the quality (sharp, dull, stabbing, color, etc.):

Q35

Does the pain radiate:

Q36

When and for how long do symptoms las each episode:

Q37

Prescription/Drug therapy*

Q38

Nutritional*

Q39

List your health goals in order of Importance:*

Q40

Motivation to achieve these goals:*

Q41

What are you hoping happens today as a result of your consultation:*

Q42

14. How often are you aware of your main problem (select one):*

Occasionally (25% of the time)

Intermittently (50% of the time)

Frequently (75% of the time)

Constantly (100% of the time)

Q43

If you cannot find a solution to your problem what do you think will happen?*

Q44

HIGHEST your blood sugar gets WITHOUT medication*

Q45

HIGHEST your blood sugar gets WITH medication*

Q46

LOWEST your blood sugar gets WITHOUT medication*

Q47

LOWEST your blood sugar gets WITH medication*

Q48

List all prescription, over-the-counter, botanicals, homeopathic, and supplements*

Q49

Surgeries/Hospitalizations and Dates

Q50

Trauma and Dates

Q51

Past/Recent Illness and Dates

Q52

Marital Status:*

Yes

No

Q53

Spouse's Name

Q54

Children / ages:

Q55

Family History (mother, father, siblings, spouse, children)*

Q56

Caffeine*

Q57

Alcohol*

Q58

Tobacco*

Q59

Do you currently have or have had in the past a known mold exposure:*

Q60

Have you ever been bitten by a tick:*

Yes

No

Q61

Have you ever been bitten by a brown recluse or other poisonous spider:*

Yes

No

Q62

Constitutional

Fatigue

Recent weight changes

Fever

Q63

Eyes

Blurred/double vision

Glasses/contacts

Eye disease or injury

Q64

Ear/Nose/Throat

Swollen glands in neck

Hearing loss or ringing

Earaches or drainage

Chronic sinus problems or rhinitis

Nose bleeds

Mouth sores/bleeding gums

Bad breath/bad taste

Sore throat or voice change

Q65

Cardiovascular

High or low blood pressure

Shortness of breath walking/lying

Heart disease

Chest pain or angina pectoris

Palpitation

Mitrial valve prolapse

Feet or ankle swelling

Shortness of breath

Spitting up blood

Q66

Psychiatric

Insomnia

Memory loss or confusion

Nervousness

Depression

Q67

Genitourinary

Frequent urination

Burning or painful urination

Blood in urine

Change in force or strain urinating

Kidney stones

Sexual difficulty

Male: testicular pain

Female: pain/irregular periods

Female: pregnant

Bladder infections

Kidney disease

Hemorrhoids

Q68

Gastrointestinal

Abdominal pain

Nausea or vomitting

Rectal bleeding/blood in stool

Painful BM/constipation

Ulcer

Change in bowel movement

Frequent diarrhea

Loss of appetite

Q69

Respiratory

Chronic or frequent cough

Spitting up blood

Pneumonia/Bronchitis

Shortness of breath

Wheezing

Asthma

Q70

Endocrine

Glandular or hormone problem

Excessive thirst or urination

Heat or cold intolerance

Skin becoming dryer

Change in hat or glove size

Diabetes

Thyroid disease

Q71

Muscuoskeletal

Back pain

Joint pain

Joint stiffness and swelling

Muscle pain or cramps

Muscle or joint weakness

Difficulty walking

Cold extremities

Q72

Integumentary (skin, breast)

Change in skin color

Change in hair or nails

Varicose veins

Breast pain/discharge

Breast lump

Hives or Eczema

Rash or itching

Q73

Neurological

Freq./recurring headaches

Migraine headache

Convulsions or seizures

Numbness or tingling

Tremors

Paralysis

Head injury

Light headed or dizzy

Stroke

Q74

Hematologic/Lymphatic/Other

Slow to heal after cuts

Easy bleeding or bruising

Anemia

Phlebitis

Past transfusion

Enlarged glands

Blood or plasma transfusion

Hepatitis

Cancer

Infectious Mono

AIDS or HIV+

Venereal

Chicken Pox

Q75

ALLERGIES / OTHER (drugs, food, or environmental)*

Q76

RECENT TESTS (lab work, x rays, CT, MRI)

Q77

Other Providers (endocrinologist, cardiologist, etc)

Q78

Reviewing Doctor:

Q79

Signature of Patient/Legal Guardian*

Q80

Print Patient Name (required)*

Q81

Print Legal Guardian Name (if necessary)

Q82

INTERNAL PRACTICE USE ONLY:

Q83

Signature of Practice Representative

Q84

Diabetes Patient Application Form -Form Fill

The only cost I will incur is the cost of any initial screening tests that I choose to undergo, which may include:

Name:*

Phone:*

Patient*

Signature*

Name*

Age

Sex:*

DOB*

Address

Address*

City

State

Zip

Cel Phone

e mail:*

Height:*

Weight:*

How Did You Hear About Us?*

Employer*

Occupation*

Length of Employment*

Main Problem(s):*

In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else. In your own words and your own opinion what do you think the real problem is*

When were you diagnosed with Type II diabetes:*

What diagnostic tools were used to achieve your diagnosis:*

What are the three things your condition has caused you to miss most:*

Severity of problem (select):*

Symptoms(list all):*

What relieves your symptoms or causes them to return:*

Describe the first time you remember having symptoms:*

What is the quality (sharp, dull, stabbing, color, etc.):

Does the pain radiate:

When and for how long do symptoms las each episode:

Prescription/Drug therapy*

Nutritional*

List your health goals in order of Importance:*

Motivation to achieve these goals:*

What are you hoping happens today as a result of your consultation:*

14. How often are you aware of your main problem (select one):*

If you cannot find a solution to your problem what do you think will happen?*

HIGHEST your blood sugar gets WITHOUT medication*

HIGHEST your blood sugar gets WITH medication*

LOWEST your blood sugar gets WITHOUT medication*

LOWEST your blood sugar gets WITH medication*

List all prescription, over-the-counter, botanicals, homeopathic, and supplements*

Surgeries/Hospitalizations and Dates

Trauma and Dates

Past/Recent Illness and Dates

Marital Status:*

Spouse's Name

Children / ages:

Family History (mother, father, siblings, spouse, children)*

Caffeine*

Alcohol*

Tobacco*

Do you currently have or have had in the past a known mold exposure:*

Have you ever been bitten by a tick:*

Have you ever been bitten by a brown recluse or other poisonous spider:*

Constitutional

Eyes

Ear/Nose/Throat

Cardiovascular

Psychiatric

Genitourinary

Gastrointestinal

Respiratory

Endocrine

Muscuoskeletal

Integumentary (skin, breast)

Neurological

Hematologic/Lymphatic/Other

ALLERGIES / OTHER (drugs, food, or environmental)*

RECENT TESTS (lab work, x rays, CT, MRI)

Other Providers (endocrinologist, cardiologist, etc)

Reviewing Doctor:

Signature of Patient/Legal Guardian*

Print Patient Name (required)*

Print Legal Guardian Name (if necessary)