Evaluation Form

New Patient Information

In order to be a good candidate for treatment, you must:

be willing to eat some combination of: meat, chicken, turkey or fish

be willing to go off birth control pills if you are presently taking them

be willing to remove alcohol from your diet

be willing to not use recreational drugs, including marijuana

be willing to remove sugar from your diet

not be participating or entering into other treatment programs

not have had an interstim device implanted

If any of these would be an issue for you, you may not be a good candidate for treatment.

Sections marked with an * are required.

Privacy Practices Acknowledgment *
Prior to completing this evaluation form, please review our Notice Of Privacy Practices. It is important that you understand your rights as a patient and acknowledge that you have reviewed the notice before we can begin treatment.

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. I authorize BOMAMED to contact me regarding treatment, appointments, payment or other health related information in the following manner:

via Postal Mail

via Email

via Phone

If you selected via Phone as a contact option, is there an authorized person(s) ONLY with whom we should leave voice message?

On occasion we may send out non-health related mailings (ie – newsletter). Would you like to be included in such mailings?

Yes No

Please type your initials this box to confirm acknowlegement of the Privacy Notice:*

Date of acknowledgement: Month Day Year *

Personal Information

Name * First Last

Date of Birth Month Day Year

Gender Male Female

Age Height Weight

Phone * Provide at least one

Home
Office
Mobile

Email * Email Address
Re-Type Email Address

Address
City State Zip
Country

Emergency Contact Name
Phone

Insurance Policy Company Policy #
Phone

Family physician Name
Phone

Referred By

Main Complaint

Have you been given a diagnosis for this problem and if so, what is it?

How long you have been experiencing this problem?

What kind of treatment(s) have you received ?

Personal Medical & Family Health History Please indicate those that are current health for your self and your family members with a "C" under appropriate person's column. "P" should be used to indicate a past problem. Leave blank those that do not apply to you.

	You	Father	Mother	Spouse	Brother	Sister	Children
Age
Allergies
Diabetes
High Blood Pressure
Seizures
Thyroid Disease
Cancer
Hepatitis
Heart Disease
HIV/Aids
Surgeries
Additional History:

Diet How Often you Eat The Following:

Red meat
Poultry
Cooked Fish
Raw Fish
Tofu
Fried Foods
Steamed Foods
Cooked Foods
Raw Foods
Bread
Potatoes
Pastas

Rice/Grains
Vegetables
Vegetable Juices
Fruit juices
Sweets
Junk Foods
Sodas
Alcohol
Sugar
Fruits
Coffee
Tea

Do you crave any particular kind of food?

Current Medications Please include vitamins, herbs, supplements, and prescriptions medications

Daily Intake

Recreational drugs (Please include cigarettes) What Kind

How Often

Please select your symptoms from the following list:

LU Shortness of breath

Chest pressure

Cough

Asthma

Skin problems

Sneeze often

Sinus problem

Production of phlegm

Frequent colds

SP Fatigue after meals

Bloating after meals

Excessive salivation

Bruise easily

Muscle weakness

Heaviness in the extremities

Undigested foods in stools

HT Palpitations or irregular heart beat

Anxiety/Depression

Chest oppression/Pain

Tongue ulceration

Varicose Veins

Arm & legs "Fall asleep easily"

KD Low back pain

Bone/Joint problems

Teeth problems

Congenital problems

Reproductive/Sexual problems

Hearing problems

Hair loss

Early Morning diarrhea

Chronic sore throats

SI Discomfort in lower middle abdomen

Food assimilation difficulty

Gas after meals

LI Constipation

Diarrhea

Foul smelling stools

Bloody stools

Hemorrhoids

Unformed stools

# of bowl movements per day

ST Epigastric discomfort

Decreased appetite

Increased appetite

Nausea

Get full easily

Discomfort associated with

Problem swallowing

Gum ulceration

# of meals per day

UB Urgent urination

Frequent urination

Difficult urination

Painful urination

Burning urination

Incontinence

Stones

Bloody urination

Cloudy urination

# of Urinations per day

LV Discomfort in left rib cage

Oppression in chest, desire to sigh

Anger easily

Depression/Mood swings

Genital itching

Oral or genital herpes

Ringing in ear(s)

Visual eye disturbances

Body Temperature Cold Time of day?

Comfortable Time of day?

Hot Time of day?

Chills/Fever Time of day?

Perspiration Hardly ever sweat

Perspire upon exertion

Perspire even while sitting or eating

Perspire while sleeping

Hot flashes

Sleep Fall asleep easily

Difficulty in falling asleep

Sleep through the night

Toss and turn in the night

Have lot of dreams

Can't really recall dreams

Wake up refreshed

Wake up exhausted

Thirst Like ice cold drinks

Like warm/hot drinks

Like room temperature drinks

Quantity of liquid per day:

Energy Low 1-4

Moderate 5-6

Very good 7-10

GB Discomfort in right rib cage

Bitter taste in mouth

Problems in decision making

Wake up at dawn and go back to sleep

Chronic ear infections

Mind Frustrated

Anger easily

Cry easily

Fearful often

Easily frightened

Obsessive thoughts

Panic attacks

Depressed often

Shyness

Irritable

Happy

Others Pain - Where?

Dizziness

Vertigo or fear of heights

Spots in visual field

Flashes of light in the visual field

Dry eyes

Watery eyes

Stuttering

Headaches - Where?

Mouth bleed when brushing teeth

Other

Weakness in the legs

Weakness in the knees

Hands and/or feet cold

Hands and/or feet swelling

Hands and feet perspire/hot frequently

Women # of days between menses

# of Tampons/Pads per day

# of days per menses

Pale blood

Red/Normal blood

Deep dark red blood

Clots

Very thick

Very muscousy

Very thin

Normal quality

Chronic discharges

Vaginal dryness/Burning

Chronic irritation/Infection

Lack of sexual desire

Strong sexual desire

Difficulty with orgasm

Birth control - Type

# of Abortions

# of Miscarriages / Problems pregnancies

# of Ectopic pregnancies

# of Births

Men Erection pain

Erection inability

Ejaculation painful

Ejaculate prematurely

Prostate enlargement

Prostate pain

Lack of sexual desire

Strong sexual desire

Sexually transmitted diseases

Sexually Transmitted Diseases

Physical assessment of pain Location of pain

Onset of pain

Duration of pain

Severity of Pain	Low 1-4 Moderate Severe 7-10
Quality of Pain	Distending Dull ache Burning Sharp Fixed Tingling Moving Pressure Radiating
Pain Aggravated by	Movement Pressure Morning Heat Rest Cold Damp After meals Evening Empty stomach
Pain Alleviated by	Movement Pressure Morning Heat Rest Cold Damp After meals Evening Empty stomach