Patient Evaluation Form
 
Were you referred?
Referred by Who?
*How did you first learn about ISCI?
Salutation
*First Name:
Middle Name
*Last Name
*Date of Birth:       
*Weight (pounds)
*Height    
*Gender:
*Address:
*City:
*State or Province:
Zip or Country Code:
*Country:
*Time Zone
*Home Phone:
Office Phone:
Cell Phone:
FAX Number:
Email:
Occupation:
Marital Status:

Parent/Guardian Information
Name:
Address:
Home Phone:
Office Phone:
Cell Phone:
Alternate Phone:

Physical Limitations
Need Assistance Walking?
Wheel Chair Needed?
Other Needs:

Emergency Contact
*Name
*Relationship:
*Phone:
*Address:
*City:
*State or Province:
Zip or Country Code:
*Country:

Physician Information
*Physician Name:
Physician Phone:
*Primary Disease Diagnosis:
*Date of Diagnosis       
*Describe All Symptoms
Medical Records Available?
Medications Now On:
Anticoagulated?
Anticoagulated Since When:       
Why Anticoagulated?
Have you ever been diagnosed with any type of cancer?
Cancer Type:
Date Cancer Diagnosed:       
Cancer Status

Patient History: Diabetes
Are you Diabetic?
Taking Insulin?

Patient History: Neurological System
Vision Decreases?
Vision Black Spots?
Vision Nistagmus?
Muscle Weakness?
Muscle Wasting?
Walking Difficulties
Decreased Hand Strength?
Fainting?
Speech Problems?
Tingling Sensation
Muscle Fasciculetions?
Spasticity?
Hyperreflexia?
Hyporeflexia?
Depression
Loss of Memory
Headaches?
Sleep Disturbances?
Dizziness?

Patient History: Pulmonary System
Asthma
Chronic Bronchitis?
Chronic Cough?
Emphysema?
Tuberculosis?

Patient History: Cardiovascular Problems
Myocardial Infarction?
Myocardial Infarction Date:       
Angina Pectoris?
Tachycardia?
By-Pass Surgery?
By-Pass Surgery Date:       
Hypertension (high blood pressure)
Hypotension (low blood pressure)?

Patient History: Circulatory
Poor Arterial Circulation?
Poor Venous Circulation?
Leg Cramps?
Tired Legs?
Varicose Veins?
Tingling Sensation in Arms and Legs?
Falling Asleep of the Hands and Legs?
Leg Ulcers?

Patient History: Gastointestinal Problems
Acid Indigestion?
Bloating?
Stomach or Duodenal Ulcer?
Stomach or Duodenal Ulcer Date?       
Loss of Appetite?
Rapid weight Gain?
Rapid Weight Loss
Overweight Problem?
Have You Had an Upper GI endoscopy?
Upper GI Date:       
Upper GI Results:
Hepatitis?
Hepatitis Type:
Gall Bladder Problems?
Gall Stones?
Icterus?
Recurring Diarrhea?
Chronis Sinusitis?
Allergic Sinus Problem?
Sinus Headaches?
Chronic Nose Bleeds?
Chronic Colds?
Soft Tissue Rheumatism?
Articular Rheumatism?
Joint Pain?
Back Pain?
Rheumatoid Arthritis?
Other Rheumatic Conditions
Diabetes Mellitus?
Overactive Thyroid?
Underactive Thyroid?
Adrenal Gland Dysfunction?
Female Menopause?
Male Menopause?
Other Endocrinological Conditions?
Food Allergy, Especially Eggs?
Vaccinations?
Hay Fever?
Allergic Asthma?
*Medication Allergies?
Medication Allergy Symptoms:
When was your last vaccination?       
Do You Smoke Cigarettes?
Do You Smoke Cigars?
Do You Smoke Pipes?
How Much Do You Smoke Per Day?
Do you drink wine?
Do you drink beer?
Do you drink hard liquor?
How Much Do You Typically Drink?
Please list any nutritional supplements you're taking:
Other Significant Illnessess:
Do you take Human Growth Hormone?
How long have you taken Growth Hormone?
Human Growth Hormone Injections per Week:
PSA Test (Men Only)?
PSA Test Date:       
PSA Test Result:
Periodic Mammograms (Women Only)?
Mammogram Test Date: