New Patient Form
Center for Natural Healthcare
Gregory J. Wastl, NESCP
3345 Lexington Ave S, Suite 101
Eagan, MN 55121
Phone: 651.287.1311
Client Information
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First Name
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Last Name
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Birth Date (MM/DD/YYYY)
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Address
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City
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State
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Zip Code
Age
Sex
Occupation
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Home Phone
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Cell Phone
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Email Address
Employer
Work Phone
Spouse's Name
Spouse's Date of Birth
Spouse's Employer
Spouse's Work Phone
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Who referred you to our office?
Emergency Contact
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First Name
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Last Name
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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
Washington DC
Zip Code
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Phone Number
Cell Phone
Email Address
Insurance and Payment Information
IMPORTANT: I understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment when a service is rendered. I also understand and agree to pay in full for all nutritional supplements at the time that I purchase them. I understand and agree that health insurance policies are an arrangement between my insurance carrier and me. This office is not responsible for any insurance billing and will not accept any checks from insurance carriers. Greg Wastl does not participate in any government or private insurance programs.
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Please read the insurance and payment information and choose one of the following:
I have read the insurance and payment information and I agree.
I have read the insurance and payment information and I disagree.
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Type Your Name
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Today's Date
Guardian Name
Today's Date
Health Questions
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(1) List the main health problems that you're coming to see me about:
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(2) List the prescription medications you are currently taking:
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(3) List the supplements, herbs, vitamins, and homeopathic remedies you are currently taking:
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(4) List any doctors or health care practitioners you have seen or are seeing for your current condition:
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(5) List any surgeries or accidents you have previously had:
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(6)
Describe what you usually eat for breakfast:
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(7) Describe what you usually eat for lunch:
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(8) Describe what you usually eat for dinner/supper:
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(9) Describe what you usually eat for a snack between meals or before bed:
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(10) Describe what you usually drink during the day and how much (water, coffee, soda, etc):
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(11) Approximately how many courses of antibiotics have you taken over your lifetime?
0-10
11-20
21+
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(12) What is the current number of dental amalgams (i.e. any silver- or black-colored fillings) in your mouth?
I have no fillings!
1-5
6-10
10+
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(13) What is the total number of fillings you have had removed?
0
1
2
3
4
5
6
7
8
9
10+
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(14) What is your current level of stress? (1 = very relaxed, 10 = very stressed)
1
2
3
4
5
6
7
8
9
10
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(15) Are you having trouble with any of the following? (Check all that apply)
Depression
Anxiety
Panic attacks
Mood swings
Anger
Frustration
Grief
Sadness
Racing Mind (especially at night)
Worry
Fear
Brain Fog
Concentration
Poor memory
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(16) Describe how you sleep? (Check all that apply)
I have problems getting to sleep
I wake up frequently
I wake up early and can't get back to sleep
I wake up unrefreshed
I wake up tired
I have night sweats
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(17) These questions relate to your exposure to electro-magnetic fields (EMFs) - Answer Yes or No:
Yes
No
Do you have fluorescent lights in your home?
Do you have a TV in your bedroom?
Do you have electrical appliances (clock, radio, lamp, phone) near your bed?
Do you use a cell phone?
Do you use an electric blanket?
Do you use magnets on your body, in your shoes, or on your bed?
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(18) How many minutes per day do you use your cell phone?
0
1-30
31-60
61-90
91-120
121+
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(19) How many hours per day do you use a computer?
0
1-2
3-4
5-6
7-8
9-10
10+
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(20) How many hours per day do you watch TV?
0
1-2
3-4
5-6
7-8
9-10
10+
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(21) Have you ever been exposed to any major environmental toxins?
Yes
No
I don't know
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(22) Have you ever been knocked unconscious or had a head injury?
Yes
No
I don't know
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(23) Have you ever had Shingles?
Yes
No
I don't know
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(24) Have you ever been told you have the Epstein Barr virus or Chronic Fatigue Syndrome?
Yes
No
I don't know
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(25) Have you ever been told you have Mononucleosis (Mono)?
Yes
No
I don't know
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(26) How many weeks of vacation do you
HAVE
each year?
0
1
2
3
4
5
6+
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(27) How many weeks of vacation do you actually
TAKE
each year?
0
1
2
3
4
5
6+
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(28) How many days per week do you exercise?
0
1
2
3
4
5
6
7
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(29) What is your exercise routine?
Symptom Inventory
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Are you having trouble with any of the following? (Check all that apply)
Fatigue/Low Energy
Headaches
Migraines
Dizziness
Allergies
Eye Sight/Vision
Hearing
Breathing/Lungs
Chest/Heart
Heartburn/Reflux
Abdominal pain/Bloating/Gas
Diarrhea
Constipation
Arthritis/Joint Pain
Numbness/Tingling in arms or legs
Skin Rash
Diabetes (High Blood Sugar)
Low Blood Sugar
Muscle Pain/Spasm
Sugar Cravings
Weight - Trouble losing or gaining
Swelling/Edema
WOMEN - PMS/Cramping
MEN - Prostate
Additional Information
If there is any other information you think I should know, please add it here:
If you would like me to send you a copy of your completed form, provide me with an email address and a copy will be sent to you.
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