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1Marchionda Imaginative Medicine Institute
PATIENT INFORMATION
General Information
Name: __________________________________________
Date of Birth: ____/____/____
Social Security Number: xxx-xx-_____ (Used as your unique medical record identifier)
Home Telephone: (______) ______-________
Work Telephone: (______) ______-________
Mobile Telephone: (______) ______-________
Email Address:
_________________________________________________________________
May we use your email to send medical related messages? ___Yes ___No
(Your email will never be sold. You will only receive emails specific to MIMI.)
Mailing Address:
_______________________________________________________________________
Physical Address (if different):
_______________________________________________________________________
City / State:
_____________________________________________________Zip Code: __________ Emergency Contact:
_____________________________________________________________
Relationship: _______________________________
Telephone: (______) ______-________ Your Occupation:
__________________________________________________________________________
Your Employer:
__________________________________________________________________________ Current Physicians / Health Providers:
Primary Care Provider:
__________________________________________________________________________
Other Providers and Specialists:
__________________________________________________________________________ How did you hear about MIMI
__________________________________________________________________________
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
2Marchionda Imaginative Medicine Institute
POLICIES
Notice of Insurance, Billing & Missed Appointment Policies
Please read and initial each section – thank you!
Marchionda Imaginative Medicine Institute (MIMI) does not participate in insurance
plans, nor submit claims, nor complete paperwork for insurance claims.
Initials _________
Payment is due in full at the time of service with cash, check or major credit card.
The returned check charge is $25.
Initials _________
We gladly accept cancellations up to 24 hours in advance without penalty. Missed
appointments without advance notice will be charged 50% of the scheduled visit fee
and future appointments will require a credit card number in advance.
Initials _________
We will provide you with an invoice with diagnosis codes (ICD10) listed that you may
submit to your insurance company for reimbursement. Some insurance companies will
honor invoices for services provided and some will not.
Initials _________
Medicare or Medicaid beneficiaries only:
Dr. Marchionda does see Medicare beneficiaries. Medicare beneficiaries need to see a
Provider that has “opted out” of Medicare, which Dr. Marchionda has done.
Initials _________
Dr. Marchionda can only see Medicaid beneficiaries for “holistic wellness visits” and
cannot act as a Medicare patient’s primary care provider.
Initials _________
I, or my legal representative, agree not to submit a claim, nor ask the practitioner to
submit a claim, to Medicare or Medicaid for items or services, even if such items or
services are otherwise covered by Medicare.
Initials _________
I have read the above policy information and by signing below agree to the terms
outlined.
Signature ______________________________________________ Date ____/____/____
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
Marchionda Imaginative Medicine Institute – MIMI’s Clinic New Patient Packet
1
Name: _____________________________________ Date: _____________________ What are the primary health conditions that you would like to address?
1)_________________________________ 2)__________________________________
3)_________________________________ 4)__________________________________ How long have you suffered with these conditions? 1. _________ 2. _________ 3. __________ 4. _________ Do you have any other health conditions that you would like help with?
_______________________________________________________________________ What have you tried doing to resolve your health conditions that Did Not work? ________________________________________________________________________ How often are you discouraged about your health? Always/ Never/ Sometimes How do these conditions interfere with the following areas in your life?
Happiness Kids Marriage/Relationships Sleep Freedom Memory
Finances Time Work Family Hobbies Life Libido Goals Other ________________________________________________________________ Do you know how this (these) conditions may have started?
________________________________________________________________________
How have you taken care of your health in the past? Medications Acupuncture/PT/Chiro Routine Medical Exercise Diet and Nutrition
Holistic Vitamins
Other: _______________
How did the previous methods work for you?
_____________________________________________________________________
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
MIMI’s Clinic New Patient Packet
2
Are there any health conditions you are afraid this might turn into?
________________________________________________________________________ ________________________________________________________________________
Autoimmunity Weight gain Heart disease Depression Surgery Arthritis
Cancer Diabetes Alzheimer’s/Dementia Genetic Variances
Other: _____________
What would be improved with better health?
Less Stress More Energy Self-Esteem Confidence Goals Purpose
Where do you picture yourself in the next 3-5 years if this problem is not taken
care of? Please be specific: ______________________________________________
_______________________________________________________________________
Are there any of the “6 Key Pillars of Health” that you would like help with?
#1 Digestive Health and Genetic Understanding #2 Balanced Hormones and Emotions #3 Nutritional Correction for Living to be 120 #4 Improved Fitness, Happiness and Lifestyle #5 Optimal Brain Function and Memory #6 Joint Health and Pain Resolution
Are you here visiting us to:
a) Resolve my immediate problem b) Lifestyle program for optimized living c) Stem cell therapy d) All of the above Other: _____________________________
What potential obstacles do you foresee that would prevent you to get the help you deserve? _______________________________________________________________________
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
MIMI’s Clinic New Patient Packet
3
Is it possible to overcome or prevent these potential barriers? _______________________________________________________________________ If we were to sit down and discuss your life 3 years from now and look back at today, what would you like to experience for you to be happy with your progress and feel like this was the most impactful health transformation possible? (This can relate to your relationships, your freedom, personal capabilities, your work, etc.) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ In helping thousands of patients just like you we have found that there are 8 mindsets that will best assist you in accomplishing your health goals. Please rate yourself on each mindset with 0% meaning, not you at all and 100% as you totally agree or you would like to have that mindset. #1 Restoring your health is your top priority and you are committed to do what it takes to start feeling better.
0% 25% 50% 75% 100% #2 Your life is a gift and you are confident that your body can heal with correct testing, treatments, lifestyle, coaching and guidance.
0% 25% 50% 75% 100% #3 You are willing to make the necessary lifestyle changes for you to achieve your goals once you have the support to lead you in the right direction.
0% 25% 50% 75% 100% #4 You are 100% committed to working with a healthcare team that focuses more on prevention and optimizing your health than on disease and medication management and wish to live a long, healthy, happy life.
0% 25% 50% 75% 100% #5 You are driven to feel great and to meet your health goals because your family, friends, co-workers, and loved ones believe in you and support you.
0% 25% 50% 75% 100%
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
MIMI’s Clinic New Patient Packet
4
#6 You see that investing in health leads to a healthier future because without your health, everything else in life loses its enjoyment and your insurance usually covers little more than costly drugs and invasive surgery.
0% 25% 50% 75% 100% #7 You understand that healing is a holistic process that involves emotional well-being, physical fitness, mental enhancement, detoxification, and are excited to share your breakthroughs with your friends and family.
0% 25% 50% 75% 100% #8 You feel you can learn how to be your own best healer and would like a sim-ple, step-by-step approach that gives you an educational curriculum so that you can get healthy and keep your health independence for the rest of your life.
0% 25% 50% 75% 100% Anything else you feel we should know about you? _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Provider Recommendations/Notes: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Thank You For Your Commitment To Your Health!
3Marchionda Imaginative Medicine Institute
Health Questionnaire - Please fill out to the best of your knowledge
Check if you have ever had:
___ Allergies
___ Arthritis
___ Asthma
___ Autoimmune disease
___Blood clots
___ Bowel disease
___ Cancer
___ Diabetes
___ Fibromyalgia
___ Frequent infections
___ Heart disease
___ High blood pressure
___ Kidney disease
___ Liver disease
___ Lung disease
___Mental illness
___ Neurologic disease
___ Skin disorder
___ Stroke
___ Thinning of bones
___ Ulcers
___ Urinary infections
WOMEN only - Check if you have ever
had:
___ Abnormal mammogram
___ Abnormal pap smear
___ Abnormal vaginal bleeding
___ Breast cancer
___ Cervical cancer
___ Fibrocystic breasts
___Ovarian cysts
___ Uterine cancer
___ Uterine growths
___ Uterine infections
MEN only - Check if you have ever had:
___ Enlarged prostate
___ Mumps
___ Prostate cancer
___ Prostate infections
___ Testicle infection
___Vasectomy
___ Other / Explain: ________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
4Marchionda Imaginative Medicine Institute
Health Questionnaire (continued...)
Surgeries (dates):
__________________________________________________________________________
__________________________________________________________________________
Allergies (drug, food, seasonal, etc.):
__________________________________________________________________________
__________________________________________________________________________
Current Medications (dose/frequency) and Supplements:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Hormones taken in PAST (dates):
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
WOMEN only - Menstrual History:
Age of first menses: _____ Date of last menses: ____/____/________
History of abnormal menses? _______ Explain:
________________________________________________________________________
Date of last pap smear: ____/____/____ Date of last mammogram: ____/____/____
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
5Marchionda Imaginative Medicine Institute
Family History
(list any conditions from category list on prior page – for deceased family members
give cause of death and approximate age)
Father: ___________________________________________________________________
Mother: ___________________________________________________________________
Paternal GF: _______________________________________________________________
Paternal GM: _______________________________________________________________
Maternal GF: _______________________________________________________________
Maternal GM: ______________________________________________________________
Siblings: ___________________________________________________________________
Health Questionnaire (continued…
Social History
Do you use tobacco? ______ How much per day? ______
Do you drink alcohol? ______ How much per day? ______
Do you exercise regularly? ______ How much per week? ______
What is your primary concern? ________________________________________________
When did this start? _________________________________________________________
What are your GOALS for your consultation?
__________________________________________________________________________
__________________________________________________________________________
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
6Marchionda Imaginative Medicine Institute
General Review - Please check any for which you have or recently have had
problems with:
General:
___ Fever
___ Night sweat
___ Weight loss
___ Weight gain
___ Fatigue
___ Change in appetite
___ Change in hair
___ Change in nails
___ Trouble tolerating hot or cold
Ears/Nose:
___ Nasal congestion
___ Nasal discharge
___ Bloody nose
___ Sinus trouble or pain
___ Decreased hearing
___ Ringing in ears
___ Ear pain or drainage
Eyes:
___ Change in vision
___ Sudden loss or decrease in vision
___ Double or blurry vision
___ Redness
___ Infection
Mouth:
___ Teeth or gum problems
___ Frequent sore throat
___ Difficulty swallowing or speaking
___ Bleeding gums
___ Mouth pain
___ Lesions
___ Hoarseness
___ Bad taste or breath
___ Change in voice
Health Questionnaire (continued...)
Skin:
___ Rash
___ Lesion or unusual mole
___ Recent change in mole size/color/
shape
Heart/Lungs:
___ Shortness of breath
___ Cough
___ Blood sputum
___ Wheezing
___ Pain with deep breath
___ Chest heaviness
___ Awaken at night short of breath
___ Heart skip beats or races
___ Fainting
___ Sleep sitting up
___ Chest pain or pressure
___ Pain or tightness in neck or arms
___ Leg or ankle swelling
Abdomen:
___ Abdominal pain
___ Pain relieved or worsened by food
___ Frequent gas or bloating
___ Heartburn or indigestion
___ Nausea / Vomiting
___ Blood in vomit
___ Constipation
___ Diarrhea
___ Blood in feces
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
7Marchionda Imaginative Medicine Institute
___ Black or tarry colored feces
___ Hemorrhoids
___ Rectal pain
Bladder:
___ Burning with urination
___ Urinating frequently
___ Get up at night to urinate
___ Recurrent bladder infections
___ Slow start of urine flow or dribbling
___ Loss of urine with cough or strain
___ Brown or pink urine
Muscular:
___ Aching or stiff muscles
___ Pain in muscles
Nerves:
___ Numbness
___ Tingling
___ Weakness in extremities
___ Loss of balance
___ Loss of coordination
___ Tremor
___ Shaking
___ Paralysis
___ Smell or taste change
Bone:
___ Bone or joint swelling or stiffness
___ Back pain
___ Neck pain
Blood:
___ Easy bruising
___ Easy bleeding
___ Blood clots
___ Varicose veins
___ Pain in calves when walking
Mental:
___ Anxiety
___ Feeling blue or sad
___ Moodiness
___ Memory loss
___ Sleep disturbance
___ Thoughts of suicide
___ Difficulty with sex
___ Family/marital difficulties
___ Trouble with alcohol/drugs
Female:
___ Abnormal periods
___ Bleeding between periods
___ Trouble with periods
___ Vaginal discharge, itch or odor
___ Breast pain, swelling or lumps
___ Nipple discharge
___ Sexual difficulties
Male:
___ Sexual difficulties
___ Discharge from penis
___ Testicular pain, swelling or lump
mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068
Name: ___________________________________________ Age: ______ Sex: _____ Date: ____________________ PART I Please list your 5 major health concerns in order of importance:1. ____________________________________________ 4. ___________________________________________ 2. ____________________________________________ 5. ___________________________________________3. ____________________________________________
PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
Metabolic Assessment Formtm
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
Category I Feeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue Pass large amount of foul-smelling gasMore than 3 bowel movements daily Use laxatives frequently
Category II Increasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swellingFrequent bloating and distention after eating Category III Intolerance to smellsIntolerance to jewelryIntolerance to shampoo, lotion, detergents, etcMultiple smell and chemical sensitivitiesConstant skin outbreaks Category IV Excessive belching, burping, or bloatingGas immediately following a mealOffensive breathDifficult bowel movementsSense of fullness during and after mealsDifficulty digesting proteins and meats; undigested food found in stools
Category VStomach pain, burning, or aching 1-4 hours after eatingUse of antacidsFeel hungry an hour or two after eatingHeartburn when lying down or bending forwardTemporary relief by using antacids, food, milk, or carbonated beveragesDigestive problems subside with rest and relaxationHeartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
Category VI Difficulty digesting roughage and fiberIndigestion and fullness last 2-4 hours after eatingPain, tenderness, soreness on left side under rib cageExcessive passage of gasNausea and/or vomitingStool undigested, foul smelling, mucus like, greasy, or poorly formedFrequent loss of appetite
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 3
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 3 0 1 2 3
0 1 2 30 1 2 3
Category VIIAbdominal distention after consumption of fiber, starches, and sugarAbdominal distention after certain probiotic or natural supplementsDecreased gastrointestinal motility, constipationIncreased gastrointestinal motility, diarrheaAlternating constipation and diarrheaSuspicion of nutritional malabsorptionFrequent use of antacid medicationHave you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?
Category VIII Greasy or high-fat foods cause distressLower bowel gas and/or bloating several hours after eatingBitter metallic taste in mouth, especially in the morningBurpy, fishy taste after consuming fish oilsUnexplained itchy skinYellowish cast to eyesStool color alternates from clay colored to normal brownReddened skin, especially palmsDry or flaky skin and/or hairHistory of gallbladder attacks or stonesHave you had your gallbladder removed?
Category IX Acne and unhealthy skinExcessive hair lossOverall sense of bloatingBodily swelling for no reasonHormone imbalancesWeight gainPoor bowel functionExcessively foul-smelling sweat
Category XCrave sweets during the dayIrritable if meals are missedDepend on coffee to keep going/get startedGet light-headed if meals are missedEating relieves fatigueFeel shaky, jittery, or have tremorsAgitated, easily upset, nervousPoor memory, forgetful between mealsBlurred vision
Category XIFatigue after mealsCrave sweets during the dayEating sweets does not relieve cravings for sugarMust have sweets after mealsWaist girth is equal or larger than hip girthFrequent urinationIncreased thirst and appetiteDifficulty losing weight
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
Yes No
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3
Category XII Cannot stay asleepCrave saltSlow starter in the morningAfternoon fatigueDizziness when standing up quicklyAfternoon headachesHeadaches with exertion or stressWeak nails
Category XIIICannot fall asleepPerspire easilyUnder a high amount of stressWeight gain when under stress Wake up tired even after 6 or more hours of sleepExcessive perspiration or perspiration with little or no activity
Category XIV Edema and swelling in ankles and wristsMuscle crampingPoor muscle enduranceFrequent urinationFrequent thirstCrave saltAbnormal sweating from minimal activityAlteration in bowel regularityInability to hold breath for long periodsShallow, rapid breathing
Category XVTired/sluggishFeel cold―hands, feet, all overRequire excessive amounts of sleep to function properlyIncrease in weight even with low-calorie dietGain weight easilyDifficult, infrequent bowel movementsDepression/lack of motivationMorning headaches that wear off as the day progressesOuter third of eyebrow thinsThinning of hair on scalp, face, or genitals, or excessive hair lossDryness of skin and/or scalpMental sluggishness
Category XVIHeart palpitationsInward tremblingIncreased pulse even at restNervous and emotionalInsomnia
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 3 0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 3 0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
Category XVI (Cont.) Night sweatsDifficulty gaining weight
Category XVII (Males Only)Urination difficulty or dribblingFrequent urinationPain inside of legs or heelsFeeling of incomplete bowel emptyingLeg twitching at night
Category XVIII (Males Only)Decreased libidoDecreased number of spontaneous morning erectionsDecreased fullness of erectionsDifficulty maintaining morning erectionsSpells of mental fatigueInability to concentrateEpisodes of depressionMuscle sorenessDecreased physical staminaUnexplained weight gainIncrease in fat distribution around chest and hipsSweating attacksMore emotional than in the past
Category XIX (Menstruating Females Only)PerimenopausalAlternating menstrual cycle lengthsExtended menstrual cycle (greater than 32 days)Shortened menstrual cycle (less than 24 days)Pain and cramping during periodsScanty blood flowHeavy blood flowBreast pain and swelling during mensesPelvic pain during mensesIrritable and depressed during mensesAcneFacial hair growthHair loss/thinning
Category XX (Menopausal Females Only)How many years have you been menopausal?Since menopause, do you ever have uterine bleeding?Hot flashesMental fogginessDisinterest in sexMood swingsDepressionPainful intercourseShrinking breastsFacial hair growthAcneIncreased vaginal pain, dryness, or itching
PART IIIHow many alcoholic beverages do you consume per week? How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times do you eat raw nuts or seeds per week?List the three worst foods you eat during the average week:List the three healthiest foods you eat during the average week:PART IVPlease list any medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
Rate your stress level on a scale of 1-10 during the average week:How many times do you eat fish per week?How many times do you work out per week?
© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3