Norbert W. Rainford, MD
200 E. Eckerson Road - Suite 200
New City, NY 10956
T: 845.639.8240
F. 845.639.8259
Email: nwr6101@gmail.com
Addresswellness.com
New Member Questionnaire
Welcome to our office! In order to best serve your medical needs, we ask that you complete our questionnaire as
completely as you can. Some questions may seem repetitious but all responses are essential.
Today’s Date:
Name
M
DOB:
(Last, First, M.I.)
F
MM/DD/YYYY
Address:
Marital
Status:
Single
Married
Separated
Divorced
Widowed
Partnered
Phone:
Home:
Cell:
Work:
E-mail Address:
Previous or referring doctor:
Contact In Case Of Emergency:
Date of last exam:
Phone:
Cell:
Is there someone with whom we can discuss your medical information:
Name of person:
Yes
No
Yes
No
Phone:
May we leave medical information on your voicemail?
Surgeries / Hospitalizations
Month and year
Reason
Type of Surgery
Hospital
1
Past or current medical history (Please check all that apply)
Angina
ADD/ADHD
Eczema
Congestive Heart Failure
Arthritis
Irritable Bowel Syndrome
Depression
Cancer (Type)
Multiple Sclerosis
Diabetes
Celiac Disease
Parkinson’s Disease
Heart attack
Kidney Disease
Irregular Heart Beat
High Blood Pressure
Stroke
Adverse Reaction To:
Caffeine:
History of:
Jaundice (turning yellow)
Irritable
Gilbert’s Syndrome or a liver disorder
Wired
Explain _____________________________________________
Aches & Pains
_____________________________________________________
Monosodium Glutamate (MSG)
Aspartame (Nutrasweet)
Exposure to Harmful Chemicals Such As:
Foods
Bananas
Herbicides
Garlic
Insecticides (frequency)
Onion
Pesticides
Cheese
Organic Solvents
Citrus foods
Heavy Metals
Chocolate
Other ________________________________________________
Alcohol
Red Wine
Sulfite containing foods
(wine, dried fruit, salad bars)
___________________________________________________________
Preservatives
(ex. Sodium Benzoate)
___________________________________________________________
2
Other
________________________________________
Dry clean your clothes frequently
Do you have any pets or farm animals
Lived or worked in a damp or moldy
__________________________________________________________
environment or ad other mold exposures
You are effected by:
__________________________________________________________
Cigarette Smoke
Work with oil based paint as artist or painter
Perfumes/Colognes
History of drinking problem
Auto Exhaust Fumes
Other _______________________________________________________________________
What kind of work do you do?
In your work or home environment, are you
exposed to:
Chemicals
Excessive Stress
Electromagnetic Radiation
Excessive Noise
Mold
Odors
Medications
Medication
Reason for Use
1)
2)
3)
4)
6)
7)
8)
3
Check if the following apply
Prolonged or regular use of NSAIDS (Advil, Aleve, etc), Motrin, Aspirin, Tylenol
Prolonged use of acid Blocking Drugs (Tagamet, Zantac, Prilosec, etc.)
Use of steroids (Prednisone, inhalers) in the past
Prolonged use of Antibiotics
Prolonged use of Antidepressants
Allergies to Meds, supplements, foods or materials such as latex
Medications/Supplements/Foods/Materials
Reaction
1)
2)
3)
4)
5)
4
Social History
Use of alcohol:
Never
Use of tobacco:
Never
Rarely
Previous smoker.
When stopped and how
many packs for how
many years
Moderate
Sometime
smoker
Daily and
how much
_______
___________
_____________
Use of recreational drugs:
Never
Rarely
Exercise Frequency:
0 -1
2-3
4-5
Exercise Type:
Weights/resistance
Cardio
Other
Diet:
Daily
Daily
6-7
List all the foods you consumed yesterday.
Breakfast:
Lunch:
Dinner:
Daytime snacks:
Night snacks:
Family Health History
Age
Father
Mother
Siblings
Health
Problems
Age
If deceased, give age at
death and cause
Siblings
If deceased, give age
at death and cause
Children
Male
Male
Female
Male
Female
Male
Female
Children
Female
Siblings
Health
Problems
Male
Female
Other
Relatives
Male
Female
5
REVIEW OF SYSTEMS
I. Constitutional
Do you feel that your health has gotten worse over the past two years?
Yes
No
Have you lost or gained or lost weight over the past two years? Gained? Lost? CIRCLE RESPONSE:
How many pounds?
Yes
No
Do you have trouble going to sleep or staying asleep?
Yes
No
Do you wake up from sleep frequently
Yes
No
How many hours of sleep do you get?
Yes
No
Do you commonly feel fatigued for no apparent reason?
Yes
No
Do you feel sleepy in the days?
Yes
No
Are there chances of you dozing off in any of the following situations: Sitting and
reading? At a movie? Watching TV? During a meeting or conference? While driving?
CIRCLE
appropriate
response
Are you frequently tired or exhausted? Are you lacking energy?
Yes
No
Do you have fever or chills or sweats at nights?
Yes
No
Do you catch every cold and flu that’s going around?
Yes
No
2. Head , Eyes , Ears, Mouth ,Throat
Do you have frequent headaches?
Yes
No
Sinus headaches?
Yes
No
Do you have morning headaches?
Yes
No
Have you experienced frequent pressure sensation in your head?
Yes
No
Do you frequently wake up in the mornings with a fullness in the head and feeling groggy?
Yes
No
Do you have ear aches?
Yes
No
Do you have frequent ringing in the ears?
Yes
No
Have you noticed a loss of hearing?
Yes
No
Do you have jaw pain or TMJ pain?
Yes
No
Do you have nosebleeds?
Yes
No
6
Do you have sinus stuffiness?
Yes
No
Do you snore?
Yes
No
Have you been told of bad breath?
Yes
No
Has your dentist told you that you have gum or periodontal disease?
Yes
No
Does your gum bleed with brushing your teeth?
Yes
No
Have you had any decrease in smelling or taste in the last few years?
Yes
No
Have you noticed any metallic taste in your mouth?
Yes
No
Have you noticed any changes in your voice?
Yes
No
Any difficulty swallowing?
Yes
No
Have you had any eye disease or injury to your eyes?
Yes
No
Do you have glaucoma or cataracts?
Yes
No
Do you have double vision or blurred vision?
Yes
No
Have you ever had any sudden loss of any field of vision?
Yes
No
3. Cardiovascular
Do you have and chest pressure, chest pain or chest discomfort?
Yes
No
If yes, are these symptoms related to stress
Yes
No
Are these symptoms related to exertion such as climbing stairs?
Yes
No
Do you have shortness of breath?
Yes
No
If yes, is the shortness of breath related to exertion or any kind of activity?
Yes
No
Are you aware of racing heart or skipping heartbeat?
Yes
No
Do you experience dizziness?
Yes
No
Have you ever fainted or nearly passed out?
Yes
No
Do you have any swelling of the legs?
Yes
No
Do you have any sores on the legs?
Yes
No
Do you have any pain or tiredness or pressure on the calves or thighs when you walk?
Yes
No
Do you have difficulty with breathing at night?
Yes
No
Have you ever been awakened at night because of shortness of breath or discomfort in chest?
Yes
No
7
Do you have any knowledge of an abnormal EKG (electrocardiogram)?
Yes
No
Have you ever been treated for angina or heart attack?
Yes
No
Do you have any knowledge of rheumatic fever in your childhood?
Yes
No
Have you ever been told of a heart murmur as a child? As an adult?
Yes
No
Are you being treated for high blood pressure?
Yes
No
Are you being treated for high cholesterol?
Yes
No
4. Respiratory
Do you have history of asthma or recurrent bronchitis or emphysema? Circle item(s)
Yes
No
Have you had a recent case of pneumonia?
Yes
No
Do you wheeze frequently?
Yes
No
Do you have a frequent cough?
Yes
No
If yes, what do you bring up?
_______________________________________________________________
Yes
No
Have you had a recent cold with a cough?
Yes
No
Do you commonly feel winded or short of breath even without exerting yourself?
Yes
No
5.Endocrinology
Do you have any knowledge of hormone or glandular problems?
Yes
No
Do you have a problem with your thyroid?
Yes
No
Do you have diabetes?
Yes
No
Are you frequently thirsty?
Yes
No
Do you urinate frequently?
Yes
No
Do you have any problems tolerating cold weather?
Yes
No
Do you have any problems tolerating warm weather?
Yes
No
Have you noticed dryness or any changes in the texture of your skin?
Yes
No
Have you noticed coldness of the hands or feet? CIRCLE response
Yes
No
8
6. Gastroenterology
Have noticed any changes in appetite? Explain
Yes
No
Have you noticed any feeling like food or liquid being stuck and not getting into stomach?
Yes
No
Do you have poor digestion?
Yes
No
Do you feel some food cause gas or bloating? Which foods?
Yes
No
Do you have chronic reflux or regurgitation?
Yes
No
Do you have recent or recurrent stomach or abdominal pain?
Yes
No
Have ever had any problems with your liver? Any yellow jaundice?
Yes
No
Have you had any problems with your gallbladder?
Yes
No
Have you had frequent diarrhea?
Yes
No
Do you have a history of peptic ulcers?
How often do you have a bowel movement? Number per day or week or month. Give
easiest response
Day:
Week:
Month:
Have you had recurrent constipation or changes in your bowel movement alternating
between constipation and loose stools?
Yes
No
Do you notice your stools being black in color?
Yes
No
Have you noticed any blood in your stools?
Yes
No
Have you noticed any mucus in your stools?
Yes
No
Do you have rectal itching?
Yes
No
Do you have frequent urination?
Yes
No
Do you have painful burning urination?
Yes
No
Do you notice bloody or “Coca-Cola” colored urine?
Yes
No
Do you notice any changes in flow of your urine?
Yes
No
Do you notice any urinary incontinence or dribbling?
Yes
No
Yes
No
Have you been told of problems with your kidney?
Yes
No
Do you have or have you had kidney stones?
Yes
No
Have you had any pain or discomfort in the pelvic area?
Yes
No
7.Genitourinary
Do you wake up more than once per night to urinate?
How many times? ________
9
Have you had any genital itching?
Yes
No
For men: Do you have loss of libido or problems with erection? Circle response
Yes
No
For women: Do you have loss of libido or vaginal dryness? Circle response
Yes
No
8.Neurological
Have you experienced episodes of memory loss or confusion?
Yes
No
Do you have lightheadedness or dizziness?
Yes
No
Have you had any numbness or tingling sensation in areas like the hands, legs, feet etc?
Yes
No
Do you have tremors or shakes?
Yes
No
Do you think you have any problems with your balance?
Yes
No
Have you ever had migraine headaches?
Yes
No
Have you ever had symptoms that look like a stroke?
Yes
No
Have you ever had a stroke?
Yes
No
Do you have a history of seizures?
Yes
No
Do you have problems with stress?
Yes
No
Do you think that you are or recently depressed?
Yes
No
Have you had nervousness or anxiety?
Yes
No
Do you have sleeping problems?
Yes
No
Have you experienced a major personal, family or work related event from which you
have not recovered fully?
Yes
No
Yes
No
Do you have frequent pain in the neck, shoulders, elbows, wrists, fingers, hips, legs,
knees, and feet? CIRCLE responses
Yes
No
Has weakness or pain of the muscles or joints limited your activity?
Yes
No
Have you noticed a loss of muscle mass?
Yes
No
9.Psychiatric
10. Musculoskeletal
Do you have frequent joint pain or stiffness or swelling?
10
11. Integumentary
Do you have rashes or itching of the skin?
Yes
No
Have you noticed any color changes of skin? If yes, please explain:
Yes
No
Have you noticed any changes in your hair or nails? If yes, please explain:
Yes
No
Have you noticed any lumps or painful areas on the skin, the armpits or breasts? If yes,
please explain:
Yes
No
Have you noticed any breast discharge?
Yes
No
12.Hematologic/Lymphatic
Do you have difficulty with healing of cuts or sores?
Yes
No
Yes
No
Do you bleed or bruise easily?
Yes
No
Do you have any history or anemia?
Yes
No
Do you have a history of cancer?
Yes
No
Do you have any swollen glands?
Yes
No
Yes
No
13. Other problems
Is there anything else that you think we should know in order to help you? If yes, explain
Yes
No
11
Signature _____________________________________
Date ____________________________________________
12