Advantage Patient FormsPlease use Google Chrome web browser to fill out these forms.New Patient FormCandida Survey"*" indicates required fieldsStep 1 of 425%Patient Information General InformationFirst Name*Middle InitialLast Name*Date of Birth* Month Day YearSocial Security*Used as your unique medical record identifierHome Telephone*Work TelephoneMobile Telephone*May we text detailed medical related messages?* Yes NoEmail* May we use your email to send medical related messages?* Yes NoYour email will never be sold to a third party. You will only receive newsletters or other emails specific to IMC or its related clinics.Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Street Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Occupation:Your Employer:Current Physicians / Health Providers Add RemoveEmergency Contact - NameEmergency Contact - TelephoneEmergency Contact - RelationshipHow did you hear about us?*Please let us know who referred you so we can show our appreciation!Policies Notice of Insurance, Billing & Missed Appointments PoliciesPlease read and initial each section, thank you!Advantage Integrative Medicine does not participate in insurance plans, nor submit claims, nor complete paperwork for insurance claims. Payment is due in full at the time of service with cash, check or major credit card. Our returned check charge is $25.InitialsDue to government regulations we are NOT able to provide services to Medicaid beneficiaries for any service that would be normally covered by Medicaid. We are allowed to provide services that are clearly not covered by Medicaid, such as low dose allergy injections or specialized IV therapies. Please contact us if you have questions about wether a specific therapy is allowed. 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. We do not have control over these practices. If your insurance company incorrectly submits claims to other offices that Dr. Rollins works in, then those claims and any payments will be returned.InitialsMedicare beneficiaries only: I understand that Medicare beneficiaries need to see one of our Providers that have “opted out” of Medicare.Initials I, or my legal representative, agree not to submit a claim, nor ask the practitioner to submit a claim, to Medicare or items or services, even if such items or services are otherwise covered by Medicare.InitialsAre you insured by* Medicare Medicaid NeitherConfirmation I confirm that I am not a Medicare or Medicaid beneficiary.Consent I read the policy information.I have read the above policy information and by entering my name below I agree to the terms outlined.Name* First Last Date* Month Day YearHealth 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 infectionsCheck if you have ever had (WOMEN only): Abnormal mammogram Abnormal pap smear Abnormal vaginal bleeding Breast cancer Cervical cancer Fibrocystic breasts Ovarian cysts Uterine cancer Uterine growths Uterine infectionsCheck if you have ever had (MEN only): Enlarged prostate Mumps Prostate cancer Prostate infections Testicle infection VasectomyOther / Explain above:Surgeries (dates):AllergiesHormones taken in PAST (dates):Current Medications (dose/frequency) and Supplements including marijuana/CBD products:Menstrual History (WOMEN only):Age of first menses:Date of last menses: Month Day YearHistory of abnormal menses? Yes NoExplain:Date of last pap smear: Month Day YearDate of last mammogram: Month Day YearFamily History (List any conditions from category list on prior page – for deceased family members give cause of death and approximate age)Mother:Father:Paternal GF:Paternal GM:Paternal GM:Maternal GF:Maternal GM:Siblings:Social HistoryDo you smoke or chew tobacco? Yes NoHow much per day?Do you drink alcohol? Yes NoHow much per day?Do you use any other drugs? Yes NoHow much per day?Do you exercise regularly? Yes NoHow much per week?How would you describe your stress level? Low Moderate HighAre you married? Yes NoDo you have kids? Yes NoHow many?Any toxic exposures, e.g. metals, pestisides, etc?What foreign countries have you visited & when?What are your GOALS for your consultation?*Symptoms 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 coldMouth: Teeth or gum problems Frequent sore throat Difficulty swallowing or speaking Bleeding gums Mouth pain Lesions Hoarseness Bad taste or breath Change in voiceBladder: Burning with urination Urinating frequently Get up at night to urinate Recurrent bladder infections Slow start of urine flow or dribbling Lose urine with cough or strain Brown or pink urineMental: Anxiety Feeling blue or sad Moodiness Memory loss Sleep disturbance Thoughts of suicide Difficulty with sex Family/marital difficulties Trouble with alcohol/drugsHeart/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 swellingBladder: Burning with urination Urinating frequently Get up at night to urinate Recurrent bladder infections Slow start of urine flow or dribbling Lose urine with cough or strain Brown or pink urineAbdomen: 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 Black or tarry colored feces Hemorrhoids Rectal painMuscular: Aching or stiff muscles Pain in musclesFemale: Abnormal periods Bleeding between periods Trouble with periods Vaginal discharge, itch or odor Breast pain, swelling or lumps Nipple discharge Sexual difficultiesMale: Discharge from penis Testicular pain, swelling or lumpBone: Bone or joint swelling or stiffness Neck pain Back painSkin: Rash Lesion or unusual mole Recent change in mole size, color or shapeBlood: Easy bruising Easy bleeding Blood clots Varicose veins Pain in calves when walkingEyes: Change in vision Sudden loss or decrease in vision Double or blurry vision Redness InfectionNerves: Numbness Tingling Weakness in extremities Loss of balance Loss of coordination Tremor Shaking Paralysis Smell or taste change Master Symptoms Questionnaire - Advantage Integrative Medicine To what degree do you experience the following? Symptom Score 0 = none 1 = mild / rarely 2 = moderate / occasionally 3 = severe / frequently 4 = extreme / alwaysEstrogen Deficiency Symptoms (women)Hot Flashes or Night Sweats 0 1 2 3 4Temperature Swings 0 1 2 3 4Difficulty Concentrating / Forgetfulness 0 1 2 3 4Mood Changes 0 1 2 3 4Loss of Skin Radiance 0 1 2 3 4Weight Gain 0 1 2 3 4Back or Joint Pains 0 1 2 3 4Episodes of Rapid Heartbeat 0 1 2 3 4Frequent Urinary Tract Infections 0 1 2 3 4Vaginal Dryness 0 1 2 3 4Painful Intercourse 0 1 2 3 4Inability to Reach Orgasm 0 1 2 3 4Progesterone Deficiency Symptoms (women)PMS 0 1 2 3 4Painful, Cystic or Swollen Breasts 0 1 2 3 4Water Retention / Swollen Fingers 0 1 2 3 4Abdominal Bloating 0 1 2 3 4Depressed Mood 0 1 2 3 4Anxiety, Irritability or Nervousness 0 1 2 3 4Headaches 0 1 2 3 4Insomnia 0 1 2 3 4Missed Periods 0 1 2 3 4Heavy and Frequent Periods 0 1 2 3 4Spotting a few days before Period 0 1 2 3 4Testosterone Deficiency SymptomsLack of Energy and Stamina 0 1 2 3 4Lack of Sexual Desire 0 1 2 3 4Flabbiness or Muscle Weakness 0 1 2 3 4Poor Body Image 0 1 2 3 4Loss of Coordination or Balance 0 1 2 3 4Decreased scalp, armpit, pubic, body hair 0 1 2 3 4Lack of Motivation 0 1 2 3 4Indecisiveness or Insecurity 0 1 2 3 4Lack of interest in activities 0 1 2 3 4Erectile difficulties (men) 0 1 2 3 4Thyroid Deficiency SymptomsFatigue, especially in morning 0 1 2 3 4Headaches, especially in morning 0 1 2 3 4Swelling or “puffiness” 0 1 2 3 4Muscle aches or joint stiffness 0 1 2 3 4Weight Gain 0 1 2 3 4Low Body Temperature 0 1 2 3 4Cold Intolerance 0 1 2 3 4Thinning Hair (diffusely all over scalp) 0 1 2 3 4Thinning Eyebrows (especially outer third) 0 1 2 3 4Brittle or slow growing nails 0 1 2 3 4Dry Skin 0 1 2 3 4Constipation 0 1 2 3 4Slow Pulse Rate 0 1 2 3 4Inability to focus or slow thinking 0 1 2 3 4Poor memory and concentration 0 1 2 3 4Depressed Mood 0 1 2 3 4Lack of interest in activities 0 1 2 3 4Cortisol Deficiency SymptomsFatigue, especially in morning 0 1 2 3 4Energy boost late morning 0 1 2 3 4Afternoon fatigue, “crash” 0 1 2 3 4Energy boost after supper / evening 0 1 2 3 4Dizziness or lightheadedness 0 1 2 3 4Low blood sugar if not eating frequently 0 1 2 3 4Shakiness or shaky hands 0 1 2 3 4Feeling of panic / inability to handle stress 0 1 2 3 4Inability to focus or slow thinking 0 1 2 3 4Rage or sudden angry outbursts 0 1 2 3 4Emotional hypersensitivity 0 1 2 3 4No patience or easily irritated 0 1 2 3 4Flu-like symptoms, achey all over 0 1 2 3 4Headaches 0 1 2 3 4Difficulty falling asleep 0 1 2 3 4Night-time awakening 0 1 2 3 4Stomach Support SymptomsExcessive belching or burping 0 1 2 3 4Gas immediately following a meal 0 1 2 3 4Bad breath 0 1 2 3 4Sense of fullness during and after meals 0 1 2 3 4Difficulty digesting fruits and vegetables 0 1 2 3 4Undigested foods in stool 0 1 2 3 4Pass large amount of foul smelling gas 0 1 2 3 4More than 3 bowel movements daily 0 1 2 3 4Frequent use of laxatives 0 1 2 3 4Difficulty with bowel movement 0 1 2 3 4Biliary Suppory SymptomsGreasy or fatty foods are bothersome 0 1 2 3 4Gas / bloating several hours after eating 0 1 2 3 4Bitter taste in mouth, esp. in morning 0 1 2 3 4Itchy skin 0 1 2 3 4Occasional clay colored stools 0 1 2 3 4Pass large amount of foul smelling gas 0 1 2 3 4More than 3 bowel movements daily 0 1 2 3 4Frequent use of laxatives 0 1 2 3 4History of gallbladder problems or removal 0 1 2 3 4Intestinal Support SymptomsFiber and roughage lead to constipation 0 1 2 3 4Indigestion 2-4 hours after eating 0 1 2 3 4Fullness 2-4 hours after eating 0 1 2 3 4Excessive belching or burping 0 1 2 3 4Pass large amount of foul smelling gas 0 1 2 3 4Nausea after eating 0 1 2 3 4Mucous or greasy appearing stools 0 1 2 3 4Loose stools 0 1 2 3 4Difficulty losing weight 0 1 2 3 4Increased thirst and appetite 0 1 2 3 4Type 1 Serotonin/Melatonin DeficiencyNight Owl - Hard to get to sleep 0 1 2 3 4Disturbed sleep, premature awakening 0 1 2 3 4Negativity, depression 0 1 2 3 4Worry, anxiety / Panic attacks / phobias 0 1 2 3 4Low self esteem 0 1 2 3 4Obsessive thoughts / behaviors 0 1 2 3 4Hyperactivity / tics 0 1 2 3 4Perfectionism, controlling behavior 0 1 2 3 4Winter blues 0 1 2 3 4Irritability, rage 0 1 2 3 4Dislike of hot weather 0 1 2 3 4Afternoon / evening cravings carbs, alcohol 0 1 2 3 4Type 2 GABA DeficiencyOverstressed and burned out 0 1 2 3 4Unable to relax / loosen up 0 1 2 3 4Stiff or tense muscles 0 1 2 3 4May experience panic attacks 0 1 2 3 4Respond well to meds, e.g. xanax 0 1 2 3 4Type 3 High Cortisol“Wired but tired” before bedtime 0 1 2 3 4Awaken alert “ready to get to work” 0 1 2 3 4Awaken agitated or hypervigilant 0 1 2 3 4Awaken startled or shocked feeling 0 1 2 3 4NameThis field is for validation purposes and should be left unchanged. "*" indicates required fieldsStep 1 of 333%First Name*Last Name*Phone*Email* Candida Questionnaire Score Sheet This questionnaire is designed for adults and the scoring system isn't appropriate for children. It lists factors in your medical history which promote the growth of the common yeast, Candida Albicans (Section A), and symptoms commonly found in individuals with yeast-connected illness (Sections B and C). For each “Yes” answer in Section A, check the box in that section. Your total score will calculate at the bottom of the section. Then move on to Sections B and C and complete as directed. Filling out and scoring this questionnaire should help you and your provider evaluate the possible role of yeasts in contributing to your health problems, but it will not provide an automatic “Yes” or “No” answer.Section A: HISTORYHave you taken antibiotics for acne for 1 month (or longer)? Yes NoHave you taken other antibiotics for 2 months or longer, or in shorter course multiple times in a single year? Yes NoHave ever you taken a broad spectrum antibiotic? Yes NoHave you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs? Yes NoHave you been pregnant? None 1 time 2 times or moreHave you taken birth control pills? No For 6 months to 2 years More than 2 yearsHave you taken steroids, such as prednisone or cortisone? No For 2 weeks or less More than 2 weeksDoes exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke... No reactions Moderate to severe symptoms Mild symptomsAre your symptoms worse on damp, muggy days or in moldy places? Yes NoHave you had athlete’s foot, ringworm, “jock itch” or other chronic fungal infections of the skin or nails? No Mild to moderate symptoms Severe or persistent symptomsDo you crave sugar? Yes NoDo you crave breads? Yes NoDo you crave alcoholic beverages? Yes NoDoes tobacco smoke really bother you? Yes NoTotal Score for Section ACandida QuestionnaireSection B: MAJOR SYMPTOMSFor each symptom which is present, enter the appropriate figure in the Point Score column: If a symptom is occasional or mild......SCORE 3 points If a symptom is frequent and/or moderately sever......SCORE 6 points If a symptom is severe and/or disabling......SCORE 9 points Fatigue or lethargy 0 3 6 9Feeling of being “drained” 0 3 6 9Poor memory 0 3 6 9Feeling “spacey” or “unreal” 0 3 6 9Inability to make decisions 0 3 6 9Numbness, burning or tingling 0 3 6 9Insomnia 0 3 6 9Muscle aches 0 3 6 9Muscle weakness or paralysis 0 3 6 9Pain and/or swelling in joints 0 3 6 9Abdominal pain 0 3 6 9Constipation 0 3 6 9Diarrhea 0 3 6 9Bloating, belching or intestinal gas 0 3 6 9Troublesome vaginal burning, itching or discharge 0 3 6 9Prostatitis 0 3 6 9Impotence 0 3 6 9Loss of sexual desire or feeling 0 3 6 9Endometriosis or infertility 0 3 6 9Cramps and/or other menstrual irregularities 0 3 6 9Premenstrual tension 0 3 6 9Attacks of anxiety or crying 0 3 6 9Cold hands or feet and/or chilliness 0 3 6 9Shaking or irritable when hungry 0 3 6 9Section B TotalCandida QuestionnaireSection C: OTHER SYMPTOMSFor each symptom which is present, enter the appropriate figure in the Point Score column: If a symptom is occasional or mild......SCORE 1 points If a symptom is frequent and/or moderately sever......SCORE 2 points If a symptom is severe and/or disabling......SCORE 3 points Drowsiness 0 1 2 3Irritability or jitteriness 0 1 2 3Loss of coordination 0 1 2 3Inability to concentrate 0 1 2 3Frequent mood swings 0 1 2 3Headaches 0 1 2 3Dizziness or loss of balance 0 1 2 3Pressure above ears or feeling of head swelling 0 1 2 3Easy bruising 0 1 2 3Chronic rashes or itching 0 1 2 3Psoriasis or recurrent hives 0 1 2 3Indigestion or heartburn 0 1 2 3Food sensitivity or intolerance 0 1 2 3Mucous in stools 0 1 2 3Rectal itching 0 1 2 3Dry mouth or throat 0 1 2 3Rashes or blisters in mouth 0 1 2 3Bad breath 0 1 2 3Foot, hair or body odor not relieved by washing 0 1 2 3Nasal congestion or post nasal drip 0 1 2 3Nasal itching 0 1 2 3Sore throat 0 1 2 3Laryngitis or loss of voice 0 1 2 3Cough or recurrent bronchitis 0 1 2 3Pain or tightness in chest 0 1 2 3Urinary frequency, urgency or incontinence 0 1 2 3Burning on urination 0 1 2 3Spots in front of eyes or erratic vision 0 1 2 3Burning or tearing of eyes 0 1 2 3Recurrent infections or fluid in ears 0 1 2 3Ear pain or deafness 0 1 2 3Section C TotalTotal Score, Section ATotal Score, Section BTotal Score, Section CGRAND TOTAL SCORE(Total score from sections A, B and C)The Grand Total Score will help us decide if your health problems are yeast-connected. Scores in women will run higher as 7 items in the questionnaire apply exclusively to women, while only 2 apply exclusively to men. WOMEN If you GRAND SCORE is: < 60 then yeast connected health problems are not likely present >60 then yeast connected health problems are possibly present >120 then yeast connected health problems are probably present >180 then yeast connected health problems are very likely present MEN If you GRAND SCORE is: < 40 then yeast connected health problems are not likely present >40 then yeast connected health problems are possibly present >90 then yeast connected health problems are probably present >140 then yeast connected health problems are very likely presentCommentsThis field is for validation purposes and should be left unchanged.
