Dr Pfau – Adult Registration Form

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ADULT REGISTRATION FORM

(AGES 16-100+)

Please print this form, fill it out on paper and bring it into our office.

 

Name: Birthdate: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:
Home Address:  
City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michegan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Phone: – –
Cell Phone: – –
Work Phone: – – x
E-mail:  
Usual occupation:  
Company:  
Referred by:  
Medical insurance:  
Person to contact in case of emergency:
Phone: – –
MEMBERS OF HOUSEHOLD:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
What would you like help with?
 

If you have recently been bothered with any of the following problems please indicate.

  1. Frequent or severe headaches
  2. Neck pains
  3. Neck lumps or swelling
  4. Loss of balance
  5. Dizzy spells
  6. Blackouts/fainting
  7. Blurry vision
  8. See halos or lights
  9. Eye pains or itching
  10. Watering eyes

 

  1. Hearing difficulties
  2. Earaches
  3. Running ears
  4. Noises in ears

 

  1. Dental problems
  2. Sore or bleeding gums

 

  1. Congested nose
  2. Running nose
  3. Sneezing spells
  4. Head colds
  5. Nosebleeds
  6. Sore throat
  7. Difficulty swallowing
  8. Hoarse voice

 

  1. Wheezing or gasping
  2. Frequent coughing
  3. Cough up phlegm
  4. Cough up blood
  5. Chest colds

 

  1. Rapid or skipped heartbeats
  2. Chest pains
  3. Shortness of breath
  4. Swollen feet or ankles
  1. Recurring indigestion
  2. Frequent belching
  3. Nausea
  4. Vomiting
  5. Pain in Abdomen
  6. Bloated Abdomen
  7. Constipation
  8. Loose bowels
  9. Black stools
  10. Pain in rectum
  11. Itching rectum
  12. Blood with stools

  1. Frequent urination
  2. Involuntary escape of urine
  3. Burning on urination
  4. Bloody urine
  5. Weak urine stream
  6. Difficulty starting
  7. Constant urge

MEN ONLY

  1. Burning / discharge
  2. Lumps/swelling testicles
  3. Painful testicles

WOMEN ONLY

  1. A missed period
  2. Menstrual problems
  3. Bleeding between periods
  4. Menstrual cramps
  5. Heavy bleeding
  6. Bearing down feeling
  7. Vaginal discharge
  8. Genital irritation
  9. Pain on intercourse
  10. Lumps in breasts
  11. Painful breasts

Number of pregnancies

Number of births

Cesareans

Abortions

  1. Aching muscles or joints
  2. Swollen joints
  3. Back or shoulder pains
  4. Weakness in arms or legs
  5. Painful feet
  6. Trembling
  7. Numbness
  8. Leg cramps

 

  1. Skin problems
  2. Scalp problems
  3. Itching or burning skin
  4. Bruises easily

 

  1. Nervousness or anxiety
  2. Nervous with strangers
  3. Nail biting
  4. Difficulty making decisions
  5. Lack of concentration
  6. Loss of memory
  7. Lonely or depressed
  8. Frequent crying
  9. Hopeless outlook
  10. Difficulty relaxing
  11. Worry a lot
  12. Frightening dreams
  13. Pessimistic
  14. Overly sensitive
  15. Irritable
  16. Rage
  17. Family problems
  18. Sexual difficulties
  19. Change of sexual energy
  20. Sought psychiatric help

 

  1. Loss or gain in weight
  2. Feel warmer or colder than others
  3. Loss of appetite
  4. Always hungry
  5. Unusual fatigue
  6. Difficulty sleeping
  7. Fever or chills
  8. Motions sickiness
  9. Excessive sweating
  10. Night sweats
  11. Hot flashes
Hospitalization (1)
Type of operation or illness:  
Year of hospitalization:  
Hospitalization (2)
Type of operation or illness:  
Year of hospitalization:  
Hospitalization (3)
Type of operation or illness:  
Year of hospitalization:  
Allergies to medications:  
Do you use: Amount:
Coffee  
Cigarettes  
Alcohol  
Birth Control Pills  
Sedatives  
Herbs/Vitamins  
 
 
 
 
Medication  
 
 
 
 
Indicate which tests you have had and when:
Chest x-ray  
Kidney x-ray  
G.L series  
Colonoscopy  
EKG  
MRI/CAT scan