<p> Stem Cell Rejuvenation Center, LLC Peace Wellness Center, PLLC </p><p>Initial Patient Intake Form</p><p>Date: </p><p>Patient Name: DOB: </p><p>List in Order of Importance what problems you want to address with the doctor:</p><p>1) 2) 3) 4) 5) </p><p>Last time you had blood work done: </p><p>Have you ever been tested for HIV □ Yes □ No Date: Results: </p><p>Have you ever been tested for Hepatitis □ Yes □ No Date: Results: </p><p>Hepatitis Diagnosis: □ Yes □ No Type: □ A □ B □ C Viral Load: </p><p>Primary Care Physician: </p><p>Other Physicians Involved in Your Care: </p><p>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</p><p>List All Surgeries & Hospitalizations, including date occurred:</p><p>7600 N. 15th Street Suite 102 • Phoenix, Arizona 85020 Phone: (602) 439-0000 • Fax: (602) 439-0021 1) 4) 2) 5) 3) 6) </p><p>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: </p><p>Did you have the following Disease (D), Get Immunized (I), or Neither (N):</p><p>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 </p><p>List Yes (Y), No (N) or Past (P) regarding use of the following: </p><p>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:______</p><p>Supplements/ Medications/Adherence/Allergies</p><p>List all Nutrient Supplements/Herbs that you are taking including the dosage. ______</p><p>Please list all prescription medication including the dosage and how often taken on the worksheet provided on page eight (8) of this form.</p><p>Do you take your medication as prescribed? □ Yes □ No</p><p>If no please explain:______</p><p>List side effects you experience from taking your prescription medication:______</p><p>Page 2 of 8 ______</p><p>Have you had any allergic reaction to the following? (Please circle Y or N)</p><p>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?______</p><p>Review of Systems</p><p>Present Weight:______Weight one year ago: ______Height:______Maximum weight and when:______Minimum weight as adult & when:______Ideal weight: ______</p><p>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.</p><p>Good Energy: Y N P Fatigue: Y N P</p><p>If you have fatigue, when in morning, afternoon, evening is it the worst?______</p><p>If you have fatigue, can you do what you need to during the day? □ Yes □ No </p><p>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):</p><p>Page 4 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:______</p><p>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</p><p>Page 5 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</p><p>Ever been diagnosed with cancer: □ Y □ N If yes, type, location, date of diagnosis and type of treatment:</p><p>EXERCISE</p><p>How often do you exercise? ______What type of exercise?______For how long?______Hobbies:______</p><p>SLEEP</p><p>How long per night?______If you wake up frequently, what is the reason?______</p><p>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</p><p>Page 6 of 8 DIET</p><p>Please list a typical day’s diet. Breakfast:</p><p>Lunch:</p><p>Dinner:</p><p>Snack: </p><p>Coffee/Tea/Soda: □ Yes □ No How many/day?______</p><p>Water intake:______glass(es)/day.</p><p>Do you have any food allergies? □ Yes □ No Please list: ______</p><p>SOCIAL LIFE</p><p>What is your occupation? </p><p>Are you exposed to chemical/biological/environmental toxins at your work? □ Yes □ No If so please explain: </p><p>Enjoy job: □ Y □ N □ P Hours worked per week:______Highest Level of Education: ______</p><p>Active spiritual practice: □ Y □ N □ P Quality of significant relationship:______</p><p>History of sexual, mental/emotional, physical abuse: □ Y □ N □ P If so, at what age and by whom:______</p><p>What is your greatest health concern:______</p><p>How does it limit you the most:______</p><p>How committed are you towards making valuable changes: □ Little □ Moderately □ Very </p><p>Are you happy with you current living situation? Explain:______</p><p>Do you have a good support system? Whom:______</p><p>Are you currently under the care of a Behavioral Health Professional: □ Y □ N </p><p>Page 7 of 8 MEDICATIONS</p><p>MEDICATION DOSAGE TIMES TAKEN REASON PRESCRIPTED BY PER DAY 1.</p><p>2.</p><p>3.</p><p>4.</p><p>5.</p><p>6.</p><p>7.</p><p>8.</p><p>9.</p><p>10.</p><p>11.</p><p>12.</p><p>13</p><p>14.</p><p>15.</p><p>Page 8 of 8</p>