Initial Patient Intake Form

Stem Cell Rejuvenation Center, LLC Peace Wellness Center, PLLC

Patient Name: DOB:

List in Order of Importance what problems you want to address with the doctor:

1) 2) 3) 4) 5)

Last time you had blood work done:

Have you ever been tested for HIV □ Yes □ No Date: Results:

Have you ever been tested for Hepatitis □ Yes □ No Date: Results:

Hepatitis Diagnosis: □ Yes □ No Type: □ A □ B □ C Viral Load:

Primary Care Physician:

Other Physicians Involved in Your Care:

Family History Father Mother Siblings Grandparents Spouse Children Age if Living: ______Age when died: ______Reason for death: ______Cancer type: ______High Blood Pressure: Y N Y N Y N Y N Y N Y N Heart Attack/Stroke: Y N Y N Y N Y N Y N Y N Heart Disease: Y N Y N Y N Y N Y N Y N Asthma/Allergies: Y N Y N Y N Y N Y N Y N Mental Illness: Y N Y N Y N Y N Y N Y N TB: Y N Y N Y N Y N Y N Y N Auto-Immune Disease: Y N Y N Y N Y N Y N Y N Diabetes Mellitus: Y N Y N Y N Y N Y N Y N Osteoporosis: Y N Y N Y N Y N Y N Y N

List All Surgeries & Hospitalizations, including date occurred:

7600 N. 15th Street Suite 102 • Phoenix, Arizona 85020 Phone: (602) 439-0000 • Fax: (602) 439-0021 1) 4) 2) 5) 3) 6)

Please Note When & Why You Have Had Each of the Following: X-Rays: MRI/Cat Scans: Ultrasounds: Accidents: TB Test: Last Dental Visit: Last Eye Exam: Last STD Testing:

Did you have the following Disease (D), Get Immunized (I), or Neither (N):

Measles: D I N Mumps: D I N Hemophilus (Hib): D I N Tetanus: D I N Chicken Pox: D I N Rubella: D I N German Measles: D I N Whooping Cough: D I N Hep B: D I N Any Vaccination Reactions: ______Scarlet Fever □ Yes □ No Rheumatic Fever □ Yes □ No

List Yes (Y), No (N) or Past (P) regarding use of the following:

Antacids: Y N P Steroids: Y N P Laxatives Y N P Analgesics: Y N P Any Alcohol Y N P Any Alcohol Y N P Addiction: Treatment: Recreational Y N P Any Drug Y N P Any Drug Y N P Drugs: Addictions: Treatment Smoking: Y N P Packs per day & number of years:______Coffee: Y N P Cups per day if yes/past:______Soda Pop Y N P Ounces per day if yes/past:______Alcohol: Y N P How often & how much if yes/past:______

Supplements/ Medications/Adherence/Allergies

List all Nutrient Supplements/Herbs that you are taking including the dosage. ______

Please list all prescription medication including the dosage and how often taken on the worksheet provided on page eight (8) of this form.

Do you take your medication as prescribed? □ Yes □ No

If no please explain:______

List side effects you experience from taking your prescription medication:______

of 8 ______

Have you had any allergic reaction to the following? (Please circle Y or N)

Local Anesthetic (e.g. Novocaine): Y N Penicillin or other antibiotics: Y N Sulfa Drugs: Y N Barbiturates (Sleeping Pills): Y N Sedatives: Y N Iodine: Y N Aspirin: Y N Latex: Y N Other: If Yes, what happens?______

Review of Systems

Present Weight:______Weight one year ago: ______Height:______Maximum weight and when:______Minimum weight as adult & when:______Ideal weight: ______

REGARDING THE NEXT LONG SECTION: Please circle (Y) if you have the problem NOW, (N) if you’ve NEVER had the problem, (P) if you had the problem in the PAST.

Good Energy: Y N P Fatigue: Y N P

If you have fatigue, when in morning, afternoon, evening is it the worst?______

If you have fatigue, can you do what you need to during the day? □ Yes □ No

SKIN Rash: Y N P Color Change: Y N P Hives: Y N P Lump: Y N P Psoriasis/Eczema: Y N P Itchy: Y N P Dry: Y N P Warts/Moles: Y N P Cancer: Y N P Perspiration: Y N P HEAD Headache: Y N P Migraine: Y N P Dandruff: Y N P Head Injury: Y N P Oil/Dry Hair: Y N P Hair Loss: Y N P EYES Dry/Watery: Y N P Blurry Vision: Y N P Double Vision: Y N P Cataracts: Y N P Glaucoma: Y N P Styes: Y N P Strain: Y N P Discharge: Y N P Itchy: Y N P Dark Under Eyelid: Y N P EARS Tinnitus (ringing): Y N P Frequent Infections: Y N P Deafness: Y N P Frequent Congestion: Y N P NOSE Page 3 of 8 Frequent Colds: Y N P Nosebleeds: Y N P Congestion: Y N P Post Nasal Drip: Y N P Polyps: Y N P Seasonal Allergies: Y N P MOUTH/THROAT Canker Sores: Y N P Cold Sores: Y N P Sore Throat: Y N P Gum Disease: Y N P Dentures: Y N P Cavities: Y N P Loss of Taste: Y N P Hoarseness: Y N P Anorexia (Loss of Y N P Thrush: Y N P Appetite): NECK Stiffness: Y N P Swollen Glands: Y N P Full Movement: Y N P Tension: Y N P RESPIRATORY Cough: Y N P TB: Y N P Cough Persistent or Y N P Emphysema/COPD: Y N P Bloody: Pneumonia: Y N P Sinus Problems: Y N P Shortness of Breath Y N P Bronchitis: Y N P w/ Exertion: Shortness of Breath Y N P Pneumonia: Y N P sitting: Shortness of Breath Y N P Asthma: Y N P Lying Down: Wheezing: Y N P Painful Breathing: Y N P CARDIOVASCULAR High Blood Y N P Rheumatic Fever: Y N P Pressure: Low Blood Y N P Murmurs: Y N P Pressure: Arrhythmias: Y N P Palpitations: Y N P Edema: Y N P Chest Pain: Y N P Circulatory Y N P Mitral Valve Prolapse: Y N P Problems: Congenital Heart Y N P Pacemaker: Y N P Lesions: Heart Disease: Y N P Stroke: Y N P High Cholesterol: Y N P URINARY TRACT Incontinence: Y N P Pain w/ Urination: Y N P Frequent Infections: Y N P Kidney Stones: Y N P Urgency: Y N P Discharge/Blood: Y N P Kidney Disease Y N P (failure):

of 8 GASTROINTESTINAL Heartburn: Y N P Bowel Movement Freq: Y N P Indigestion: Y N P Recent BM Change: Y N P Bloating: Y N P Diarrhea/Constipation: Y N P Nausea: Y N P Hemorrhoids: Y N P Vomiting: Y N P Gall Bladder Disease Y N P Change in Appetite: Y N P Liver Disease: Y N P Pancreatitis: Y N P Ulcer: Y N P Elevated Liver Y N P Jaundice: Y N P Function: MALE GENITALIA Testicular Y N P Sexually Active: Y N P pain/swelling: Hernia: Y N P S.T.D. Y N P Discharge: Y N P Prostate Y N P Disease/Symptoms: Impotency: Y N P Sexual Orientation: Hetero □ Homo □ Bi □ FEMALE GENITALIA Age Period Began: How Often Period Occurs: How Long Period Heavy Menstrual Y N P Lasts: Bleeding: Menstrual Y N P Menstrual Pain: Y N P Cramping: PMS: Y N P Food Cravings: Y N P Times Pregnant: How Many Births: Miscarriages: Abortions: Last Pap Smear: Diagnosis: Any Abnormal Paps: Y N P When Was Abnormal: Menopausal Since Use of Hormones: Y N P What Age: Type of Hormones Healthy Libido: Y N P Used: Dry Vagina: Y N P Sexually Active: Y N P Pain w/ Intercourse: Y N P Vaginitis: Y N P S.T.D. Y N P Mammography: Y N P Dexa Scan: Y N P If Yes, what were results: Pelvic Inflammatory Y N P PCOS: Y N P Disease: Please list any birth control used and ages used:______

MUSCULOSKELETAL Weakness: Y N P Arthritis: Y N P Stiffnes: Y N P Leg Cramps: Y N P Tremors: Y N P Pain: Y N P Hernia: Y N P NERVOUS Paralysis: Y N P Sciatica: Y N P Tingling/Numbness: Y N P Carpal Tunnel Y N P Syndrome: Seizures: Y N P Fainting: Y N P Epilepsy: Y N P Meningitis: Y N P Neuropathy: Y N P

of 8 ENDOCRINE/AUTO-IMMUNE/BLOOD Anemia: Y N P Lupus: Y N P Multiple Sclerosis: Y N P Rheumatoid Arthritis: Y N P Blood Disease: Y N P Diabetes: Y N P Bleeding Tendency: Y N P Thyroid Problems: Y N P Chronic Fatigue Y N P Syndrome: COMMON DISORDERS ASSOCIATED WITH HIV/AIDS Coccidiomycosis Y N P Shingles: Y N P (Valley Fever): PML: Y N P Thrush: Y N P MAC: Y N P Neuropathy: Y N P PCP: Y N P Cryptococcosis: Y N P Histoplasmosis: Y N P Cryptosporidiosis: Y N P Toxoplama: Y N P Gondii: Y N P CMV: Y N P STD Herpes: Y N P Gonorrhea: Y N P HPV (Venereal Y N P Lymphogranuloma Y N P Warts): Venereum: Syphilis: Y N P Chancroid: Y N P Chlamydia: Y N P Crabs: Y N P Molluscum Y N P Contagiosum: MENTAL/EMOTIONAL Depression: Y N P Anger/Irritability: Y N P Suicidal: Y N P High-Strung/Tense: Y N P Anxiety: Y N P Fear/Panic: Y N P Eating Disorder: Y N P Psych Hospitalization: Y N P

Ever been diagnosed with cancer: □ Y □ N If yes, type, location, date of diagnosis and type of treatment:

EXERCISE

How often do you exercise? ______What type of exercise?______For how long?______Hobbies:______

How long per night?______If you wake up frequently, what is the reason?______

Nightmares: Y N P Wake Refreshed: Y N P Must Nap During Y N P the Day: Sleep Walk: Y N P Grind Teeth: Y N P Snore: Y N P

of 8 DIET

Please list a typical day’s diet. Breakfast:

Lunch:

Dinner:

Snack:

Coffee/Tea/Soda: □ Yes □ No How many/day?______

Water intake:______glass(es)/day.

Do you have any food allergies? □ Yes □ No Please list: ______

SOCIAL LIFE

What is your occupation?

Are you exposed to chemical/biological/environmental toxins at your work? □ Yes □ No If so please explain:

Enjoy job: □ Y □ N □ P Hours worked per week:______Highest Level of Education: ______

Active spiritual practice: □ Y □ N □ P Quality of significant relationship:______

History of sexual, mental/emotional, physical abuse: □ Y □ N □ P If so, at what age and by whom:______

What is your greatest health concern:______

How does it limit you the most:______

How committed are you towards making valuable changes: □ Little □ Moderately □ Very

Are you happy with you current living situation? Explain:______

Do you have a good support system? Whom:______

Are you currently under the care of a Behavioral Health Professional: □ Y □ N

of 8 MEDICATIONS

MEDICATION DOSAGE TIMES TAKEN REASON PRESCRIPTED BY PER DAY 1.