New Patient Form - Richard Malik, ND

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Name*
First Last
Physical Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Physical address and mailing address are different.
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Email*
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Health Concerns (in order of importance)
Please list your health concerns here:
Concern Duration

Click "+" to add another row.
Vitamins, Herbs, Supplements, & Homeopathics
Please list all you are taking here:
Name/Type Dose/day (mg, IU, etc.) Reason

Click "+" to add another row.
Drugs: Prescription and over the counter you are now taking
Please list all you are taking here:
Drug Dose Reason Prescribing Doctor

Click "+" to add another row.
Allergies:
- No Known Drug Allergies
Non Life Threatening Allergies (drugs, food, grass, pollen, chemicals, etc.)
Reaction
Life Threatening Allergies (drugs, food, grass, pollen, chemicals, etc.)
Reaction
Current Physicians, Doctors, & Health Provider Contact Information:
List provider name, specialty, address, and contact information, if possible
Illnesses & Medical Conditions: Please include emotional and physical trauma /accidents
Please list all illnesses and medical conditions here. Please include emotional and physical trauma /accidents.
Date Type Treatment

Click "+" to add another row.
Procedures & Hospitalizations:
Please list all procedures and hospitalizations here:
Date Type (surgery/special test) Reason Outcome

Click "+" to add another row.
Family Medical History: (circle all relatives that apply)
M=Mother F=Father B=Brother S=Sister G=Grandparent C=Child
Allergies
- M
- F
- B
- S
- G
- C
Alcoholism
- M
- F
- B
- S
- G
- C
Alzheimer’s Disease
- M
- F
- B
- S
- G
- C
Anemia
- M
- F
- B
- S
- G
- C
Anxiety
- M
- F
- B
- S
- G
- C
Arthritis
- M
- F
- B
- S
- G
- C
Asthma
- M
- F
- B
- S
- G
- C
Auto-immune Disease
- M
- F
- B
- S
- G
- C
Bleeding Tendency
- M
- F
- B
- S
- G
- C
Breast Cancer
- M
- F
- B
- S
- G
- C
Colon Cancer
- M
- F
- B
- S
- G
- C
Ovarian Cancer
- M
- F
- B
- S
- G
- C
Depression
- M
- F
- B
- S
- G
- C
Diabetes
- M
- F
- B
- S
- G
- C
Epilepsy
- M
- F
- B
- S
- G
- C
Heart Disease
- M
- F
- B
- S
- G
- C
High Blood Pressure
- M
- F
- B
- S
- G
- C
High Cholesterol
- M
- F
- B
- S
- G
- C
Kidney Disease
- M
- F
- B
- S
- G
- C
Obesity
- M
- F
- B
- S
- G
- C
Psychological Disease
- M
- F
- B
- S
- G
- C
Stroke
- M
- F
- B
- S
- G
- C
Thyroid
- M
- F
- B
- S
- G
- C
Other Family History
Other
- M
- F
- B
- S
- G
- C
Social History:
Marital Status
- Single
- Married
- Divorced
- Widowed
- Significant Other
Children (year of birth and name):
Occupation:
Hobbies/Interests:
Who provides you with social support?
Do you have a spiritual or religious practice?
What do you do to relax or unwind?
Do you smoke?
- yes
- no
How much?
Do you use other tobacco products?
- yes
- no
What forms?
How much?
Do you drink alcohol?
- yes
- no
How much?
Do you drink caffeine?
- Yes
- No
What forms? How much? How often?
Do you do recreational drugs?
- yes
- no
What drugs and how often:
Exercise: Include type, how long per session, frequency, and how long you have been doing it
Is there anything else I should know?
Use the codes listed below. Please indicate a number from 0 to 4 next to each symptom to describe what you have experienced in the last 3 months. 0 = Never 1 = Rarely 2 = Occasionally 3 = Often 4 = Always
Constitutional
Weight Loss*
- Never
- Rarely
- Occasionally
- Often
- Always
Weight Gain*
- Never
- Rarely
- Occasionally
- Often
- Always
Fevers/Chills*
- Never
- Rarely
- Occasionally
- Often
- Always
Weakness*
- Never
- Rarely
- Occasionally
- Often
- Always
Fatigue*
- Never
- Rarely
- Occasionally
- Often
- Always
Sweats/Night Sweats*
- Never
- Rarely
- Occasionally
- Often
- Always
Sensitivity to Heat*
- Never
- Rarely
- Occasionally
- Often
- Always
Sensitivity to Cold*
- Never
- Rarely
- Occasionally
- Often
- Always
Frequent Infections*
- Never
- Rarely
- Occasionally
- Often
- Always
Skin
Rash*
- Never
- Rarely
- Occasionally
- Often
- Always
Acne*
- Never
- Rarely
- Occasionally
- Often
- Always
Hives*
- Never
- Rarely
- Occasionally
- Often
- Always
Eczema*
- Never
- Rarely
- Occasionally
- Often
- Always
Itching*
- Never
- Rarely
- Occasionally
- Often
- Always
Sweating*
- Never
- Rarely
- Occasionally
- Often
- Always
Dry Skin*
- Never
- Rarely
- Occasionally
- Often
- Always
Brittle Nails*
- Never
- Rarely
- Occasionally
- Often
- Always
Abnormal Color*
- Never
- Rarely
- Occasionally
- Often
- Always
Bleeding*
- Never
- Rarely
- Occasionally
- Often
- Always
Bruising*
- Never
- Rarely
- Occasionally
- Often
- Always
Lymphatic
Enlarged Lymph Nodes*
- Never
- Rarely
- Occasionally
- Often
- Always
Tender Lymph Nodes*
- Never
- Rarely
- Occasionally
- Often
- Always
Discharge from Lymph Nodes*
- Never
- Rarely
- Occasionally
- Often
- Always
Head
Headache*
- Never
- Rarely
- Occasionally
- Often
- Always
Migraine*
- Never
- Rarely
- Occasionally
- Often
- Always
Injury*
- Never
- Rarely
- Occasionally
- Often
- Always
Trauma*
- Never
- Rarely
- Occasionally
- Often
- Always
Fainting*
- Never
- Rarely
- Occasionally
- Often
- Always
Seizures*
- Never
- Rarely
- Occasionally
- Often
- Always
Eyes
Vision Changes*
- Never
- Rarely
- Occasionally
- Often
- Always
Blurring*
- Never
- Rarely
- Occasionally
- Often
- Always
Inflammation to Eye*
- Never
- Rarely
- Occasionally
- Often
- Always
Eye Pain*
- Never
- Rarely
- Occasionally
- Often
- Always
Eye Discharge*
- Never
- Rarely
- Occasionally
- Often
- Always
Double Vision*
- Never
- Rarely
- Occasionally
- Often
- Always
Blind Spots*
- Never
- Rarely
- Occasionally
- Often
- Always
Floaters or Halos*
- Never
- Rarely
- Occasionally
- Often
- Always
Glaucoma*
- Never
- Rarely
- Occasionally
- Often
- Always
Ears
Diminished Hearing*
- Never
- Rarely
- Occasionally
- Often
- Always
Ear Pain*
- Never
- Rarely
- Occasionally
- Often
- Always
Ear Discharge*
- Never
- Rarely
- Occasionally
- Often
- Always
Tinnitus*
- Never
- Rarely
- Occasionally
- Often
- Always
Vertigo*
- Never
- Rarely
- Occasionally
- Often
- Always
Dizziness*
- Never
- Rarely
- Occasionally
- Often
- Always
Nose, Mouth & Throat
Nose Bleeding*
- Never
- Rarely
- Occasionally
- Often
- Always
Obstruction*
- Never
- Rarely
- Occasionally
- Often
- Always
Sinusitis*
- Never
- Rarely
- Occasionally
- Often
- Always
Post-Nasal Drip*
- Never
- Rarely
- Occasionally
- Often
- Always
Throat Pain*
- Never
- Rarely
- Occasionally
- Often
- Always
Sore Throat*
- Never
- Rarely
- Occasionally
- Often
- Always
Mouth Sores*
- Never
- Rarely
- Occasionally
- Often
- Always
Tooth Problems*
- Never
- Rarely
- Occasionally
- Often
- Always
Hoarseness*
- Never
- Rarely
- Occasionally
- Often
- Always
Change in Voice*
- Never
- Rarely
- Occasionally
- Often
- Always
Goiter*
- Never
- Rarely
- Occasionally
- Often
- Always
Respiratory
Difficulty Breathing*
- Never
- Rarely
- Occasionally
- Often
- Always
↓ Exercise Tolerance*
- Never
- Rarely
- Occasionally
- Often
- Always
Cough*
- Never
- Rarely
- Occasionally
- Often
- Always
Sputum*
- Never
- Rarely
- Occasionally
- Often
- Always
Bloody Sputum*
- Never
- Rarely
- Occasionally
- Often
- Always
Wheezing*
- Never
- Rarely
- Occasionally
- Often
- Always
Cardiovascular
Shortness of Breath*
- Never
- Rarely
- Occasionally
- Often
- Always
Chest Pain*
- Never
- Rarely
- Occasionally
- Often
- Always
Palpitations*
- Never
- Rarely
- Occasionally
- Often
- Always
High Blood Pressure*
- Never
- Rarely
- Occasionally
- Often
- Always
High Blood Cholesterol*
- Never
- Rarely
- Occasionally
- Often
- Always
Swelling of Limbs*
- Never
- Rarely
- Occasionally
- Often
- Always
Gastrointestinal
↑ appetite*
- Never
- Rarely
- Occasionally
- Often
- Always
↓ appetite*
- Never
- Rarely
- Occasionally
- Often
- Always
Mouth Sores*
- Never
- Rarely
- Occasionally
- Often
- Always
Change in Taste*
- Never
- Rarely
- Occasionally
- Often
- Always
Heart Burn*
- Never
- Rarely
- Occasionally
- Often
- Always
Belching*
- Never
- Rarely
- Occasionally
- Often
- Always
Constipation*
- Never
- Rarely
- Occasionally
- Often
- Always
Diarrhea*
- Never
- Rarely
- Occasionally
- Often
- Always
Nausea*
- Never
- Rarely
- Occasionally
- Often
- Always
Vomiting*
- Never
- Rarely
- Occasionally
- Often
- Always
Choking Feeling*
- Never
- Rarely
- Occasionally
- Often
- Always
Difficulty Swallowing*
- Never
- Rarely
- Occasionally
- Often
- Always
Indigestion*
- Never
- Rarely
- Occasionally
- Often
- Always
Gas*
- Never
- Rarely
- Occasionally
- Often
- Always
Bloating*
- Never
- Rarely
- Occasionally
- Often
- Always
Abdominal Cramps*
- Never
- Rarely
- Occasionally
- Often
- Always
Pants Soiling*
- Never
- Rarely
- Occasionally
- Often
- Always
Rectal Bleeding*
- Never
- Rarely
- Occasionally
- Often
- Always
Mucous in Stool*
- Never
- Rarely
- Occasionally
- Often
- Always
Blood in Stool*
- Never
- Rarely
- Occasionally
- Often
- Always
Genitourinary
Pain Upon Urination*
- Never
- Rarely
- Occasionally
- Often
- Always
Frequent Urination*
- Never
- Rarely
- Occasionally
- Often
- Always
Urinary Urgency*
- Never
- Rarely
- Occasionally
- Often
- Always
Urinary Incontinence*
- Never
- Rarely
- Occasionally
- Often
- Always
Bedwetting*
- Never
- Rarely
- Occasionally
- Often
- Always
Bladder Pain or Discomfort*
- Never
- Rarely
- Occasionally
- Often
- Always
Urinary Tract Infections*
- Never
- Rarely
- Occasionally
- Often
- Always
Blood in Urine*
- Never
- Rarely
- Occasionally
- Often
- Always
Excessive Vaginal Discharge*
- Never
- Rarely
- Occasionally
- Often
- Always
Vaginal Itching*
- Never
- Rarely
- Occasionally
- Often
- Always
Irregular Menses*
- Never
- Rarely
- Occasionally
- Often
- Always
Menstrual Cramps*
- Never
- Rarely
- Occasionally
- Often
- Always
Premenstrual Symptoms*
- Never
- Rarely
- Occasionally
- Often
- Always
Genital Ulcers*
- Never
- Rarely
- Occasionally
- Often
- Always
Lack of Sexual Interest*
- Never
- Rarely
- Occasionally
- Often
- Always
Pain with Intercourse*
- Never
- Rarely
- Occasionally
- Often
- Always
Jock Itch*
- Never
- Rarely
- Occasionally
- Often
- Always
Impotence*
- Never
- Rarely
- Occasionally
- Often
- Always
Pain with Orgasm*
- Never
- Rarely
- Occasionally
- Often
- Always
Breasts
Breast Masses*
- Never
- Rarely
- Occasionally
- Often
- Always
Breast Pain*
- Never
- Rarely
- Occasionally
- Often
- Always
Nipple Discharge*
- Never
- Rarely
- Occasionally
- Often
- Always
Muscle & Joint
Leg Pains*
- Never
- Rarely
- Occasionally
- Often
- Always
Muscle Cramps*
- Never
- Rarely
- Occasionally
- Often
- Always
Muscle Aches or Pains*
- Never
- Rarely
- Occasionally
- Often
- Always
Muscle Spasms, Twitching*
- Never
- Rarely
- Occasionally
- Often
- Always
Muscle Weakness*
- Never
- Rarely
- Occasionally
- Often
- Always
Restless Legs at Night*
- Never
- Rarely
- Occasionally
- Often
- Always
Stiff Joints*
- Never
- Rarely
- Occasionally
- Often
- Always
Painful Joints*
- Never
- Rarely
- Occasionally
- Often
- Always
Swelling of Joints*
- Never
- Rarely
- Occasionally
- Often
- Always
Redness, Warmth of Joints*
- Never
- Rarely
- Occasionally
- Often
- Always
Bone Pain*
- Never
- Rarely
- Occasionally
- Often
- Always
Neurological & Psychological
Weakness*
- Never
- Rarely
- Occasionally
- Often
- Always
Numbness*
- Never
- Rarely
- Occasionally
- Often
- Always
Tingling*
- Never
- Rarely
- Occasionally
- Often
- Always
Burning Sensations*
- Never
- Rarely
- Occasionally
- Often
- Always
Shooting Sensations*
- Never
- Rarely
- Occasionally
- Often
- Always
Undue Fatigue*
- Never
- Rarely
- Occasionally
- Often
- Always
Depression*
- Never
- Rarely
- Occasionally
- Often
- Always
Irritability*
- Never
- Rarely
- Occasionally
- Often
- Always
Hyperactivity*
- Never
- Rarely
- Occasionally
- Often
- Always
Restlessness*
- Never
- Rarely
- Occasionally
- Often
- Always
Nervousness*
- Never
- Rarely
- Occasionally
- Often
- Always
Anxiety*
- Never
- Rarely
- Occasionally
- Often
- Always
Fear*
- Never
- Rarely
- Occasionally
- Often
- Always
Difficulty Making Decisions*
- Never
- Rarely
- Occasionally
- Often
- Always
Amnesia*
- Never
- Rarely
- Occasionally
- Often
- Always
Short-Term Memory Loss*
- Never
- Rarely
- Occasionally
- Often
- Always
Mental Confusion*
- Never
- Rarely
- Occasionally
- Often
- Always
Learning Problems*
- Never
- Rarely
- Occasionally
- Often
- Always
Lack of Concentration*
- Never
- Rarely
- Occasionally
- Often
- Always
Loss of Interest in Job/Hobby*
- Never
- Rarely
- Occasionally
- Often
- Always
Insomnia*
- Never
- Rarely
- Occasionally
- Often
- Always
Clumsiness*
- Never
- Rarely
- Occasionally
- Often
- Always
Explosive Behavior*
- Never
- Rarely
- Occasionally
- Often
- Always
Bizarre Behavior*
- Never
- Rarely
- Occasionally
- Often
- Always
Aggressive Behavior*
- Never
- Rarely
- Occasionally
- Often
- Always
Miscellaneous
Excessive Thirst*
- Never
- Rarely
- Occasionally
- Often
- Always
Excessive Hunger*
- Never
- Rarely
- Occasionally
- Often
- Always
Hair Loss*
- Never
- Rarely
- Occasionally
- Often
- Always
Feel Great All Day*
- Never
- Rarely
- Occasionally
- Often
- Always
CAPTCHA

Concern	Duration

Name/Type	Dose/day (mg, IU, etc.)	Reason

Drug	Dose	Reason	Prescribing Doctor

Date	Type	Treatment

Thank you for communicating with us electronically!

To ensure your privacy, this website is secured with 256 bit SSL data encryption.

Health Concerns (in order of importance)

Vitamins, Herbs, Supplements, & Homeopathics

Drugs: Prescription and over the counter you are now taking

Allergies:

Illnesses & Medical Conditions: Please include emotional and physical trauma /accidents

Procedures & Hospitalizations:

Family Medical History: (circle all relatives that apply) M=Mother F=Father B=Brother S=Sister G=Grandparent C=Child

Social History:

Use the codes listed below. Please indicate a number from 0 to 4 next to each symptom to describe what you have experienced in the last 3 months. 0 = Never 1 = Rarely 2 = Occasionally 3 = Often 4 = Always

Constitutional

Skin

Lymphatic

Head

Eyes

Ears

Nose, Mouth & Throat

Respiratory

Cardiovascular

Gastrointestinal

Genitourinary

Breasts

Muscle & Joint

Neurological & Psychological

Miscellaneous

Family Medical History: (circle all relatives that apply)
M=Mother F=Father B=Brother S=Sister G=Grandparent C=Child