What name do you prefer to be called?
How did you hear about us?
Where do you work?
What is the best way to contact you?
May we call you at home?
May we call you at work?
May we leave a message for you at home?
If Yes, Name(s)
May we leave a message for you at work?
If Yes, Name(s)
Single Significant Other Married Divorced Widowed
Are there restrictions in our communication with your spouse or caregiver (especially on the of day procedure)?
Have you or a family member seen Dr. Holdredge as a patient before today?
What is your main concern for today's visit?
Have you seen someone else regarding this concern before today?
If so, were you treated?
Primary Care Physician
Referred by Someone Other Than Physician
Have you ever been diagnosed with, or treated for, any of the following conditions?
Diabetes Fainting spells Asthma/COPD Difficulty breathing climbing stairs/lying flat Sleep apnea C-PAP machine Claustrophobia Needle phobia Anxiety/depression Alcohol/drug dependency Bipolar disorder Thyroid problems Seizures ALS MS Myasthenia Gravis HIV/AIDS Hepatitis A, B, or C Skin cancer (basal, squamous, melanoma) Other cancer Chemotherapy Radiation High blood pressure Heart disease Stents or bypass Cardiac pacemaker Chest pain Stroke Bleeding disorder Easy bruising Heavy menstrual bleeding Anemia Stomach/duodental ulcer Intestinal bleeding GI problems Kidney or bladder problems Kidney stones Rheumatoid arthritis Autoimmune disease Eczema Psoriasis Acne Rosacea
Are you under the care of a physician for any of the above conditions?
What treatments have been carried out?
Treating Physician Name & Address
Have you ever taken Accutane (Isotretinoin)?
Date of Last Dose
Do you take Aspirin, Nsaids, Plavix, Coumadin, or anything that interferes with normal blood clotting?
Current Medications Including Vitamins and Supplements
Any conditions or medications that suppress the immune system?
Do you smoke cigarettes, cigars, or a pipe? If so, how much and for how long?