Patient Information 2023 Form "*" indicates required fields Step 1 of 7 14% Patient Information General InformationName* First Middle Last Date of Birth* Month Day Year Social Security*Used as your unique medical record identifierHome Telephone*Work TelephoneMobile Telephone*May we leave detailed medical related messages?* Yes No Email* CHECK WHO IS THEIR NEWSLETTER PLATFORM May we use your email to send medical related messages?* Yes No Your 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 - Name Emergency Contact - Telephone Emergency Contact - Relationship How did you hear about us? 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. Initials Due to government regulations we are NOT able to provide services to Medicaid beneficiariesfor 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. Initials Medicare beneficiaries only: Dr. Rollins does not see Medicare beneficiaries. 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. Initials By signing below, I confirm that I am not a Medicare or Medicaid beneficiary.Signature Reset signature Signature locked. Reset to sign again DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I have read the above policy information and by signing below agree to the terms outlined.Signature Reset signature Signature locked. Reset to sign again DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 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 Check 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 infections Check if you have ever had (MEN only): Enlarged prostate Mumps Prostate cancer Prostate infections Testicle infection Vasectomy Other / Explain above: Surgeries (dates): Allergies: Current Medications (dose/frequency) and Supplements including marijuana/CBD products: Hormones taken in PAST (dates): Menstrual History (WOMEN only):Age of first menses:Date of last menses: Month Day Year History of abnormal menses? Yes No Explain:Date of last pap smear: Month Day Year Date of last mammogram: Month Day Year 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: Paternal GM: Maternal GF: Maternal GM: Siblings: Social History Do you smoke or chew tobacco? Yes No How much per day? Yes No Do you drink alcohol? Yes No How much per day? Yes No Do you use any other drugs? Yes No How much per day? Yes No Do you exercise regularly? Yes No How much per week? Yes No How would you describe your stress level? Low Moderate High Are you married? Yes No Do you have kids? Yes No How 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 cold 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 Bladder: 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 urine Mental: Anxiety Feeling blue or sad Moodiness Memory loss Sleep disturbance Thoughts of suicide Difficulty with sex Family/marital difficulties Trouble with alcohol/drugs 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 Bladder: 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 urine 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 Black or tarry colored feces Hemorrhoids Rectal pain Muscular: Aching or stiff muscles Pain in muscles Female: Abnormal periods Bleeding between periods Trouble with periods Vaginal discharge, itch or odor Breast pain, swelling or lumps Nipple discharge Sexual difficulties Male: Discharge from penis Testicular pain, swelling or lump Bone: Bone or joint swelling or stiffness Neck pain Back pain Skin: Rash Lesion or unusual mole Recent change in mole size, color or shape Blood: Easy bruising Easy bleeding Blood clots Varicose veins Pain in calves when walking Eyes: Change in vision Sudden loss or decrease in vision Double or blurry vision Redness Infection Nerves: 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 4 Temperature Swings 0 1 2 3 4 Difficulty Concentrating / Forgetfulness 0 1 2 3 4 Mood Changes 0 1 2 3 4 Loss of Skin Radiance 0 1 2 3 4 Weight Gain 0 1 2 3 4 Back or Joint Pains 0 1 2 3 4 Episodes of Rapid Heartbeat 0 1 2 3 4 Frequent Urinary Tract Infections 0 1 2 3 4 Vaginal Dryness 0 1 2 3 4 Painful Intercourse 0 1 2 3 4 Inability to Reach Orgasm 0 1 2 3 4 Progesterone Deficiency Symptoms (women) PMS 0 1 2 3 4 Painful, Cystic or Swollen Breasts 0 1 2 3 4 Water Retention / Swollen Fingers 0 1 2 3 4 Abdominal Bloating 0 1 2 3 4 Depressed Mood 0 1 2 3 4 Anxiety, Irritability or Nervousness 0 1 2 3 4 Headaches 0 1 2 3 4 Insomnia 0 1 2 3 4 Missed Periods 0 1 2 3 4 Heavy and Frequent Periods 0 1 2 3 4 Spotting a few days before Period 0 1 2 3 4 Testosterone Deficiency Symptoms Lack of Energy and Stamina 0 1 2 3 4 Lack of Sexual Desire 0 1 2 3 4 Flabbiness or Muscle Weakness 0 1 2 3 4 Poor Body Image 0 1 2 3 4 Loss of Coordination or Balance 0 1 2 3 4 Decreased scalp, armpit, pubic, body hair 0 1 2 3 4 Lack of Motivation 0 1 2 3 4 Indecisiveness or Insecurity 0 1 2 3 4 Lack of interest in activities 0 1 2 3 4 Erectile difficulties (men) 0 1 2 3 4 Thyroid Deficiency Symptoms Fatigue, especially in morning 0 1 2 3 4 Headaches, especially in morning 0 1 2 3 4 Swelling or “puffiness” 0 1 2 3 4 Muscle aches or joint stiffness 0 1 2 3 4 Weight Gain 0 1 2 3 4 Low Body Temperature 0 1 2 3 4 Cold Intolerance 0 1 2 3 4 Thinning Hair (diffusely all over scalp) 0 1 2 3 4 Thinning Eyebrows (especially outer third) 0 1 2 3 4 Brittle or slow growing nails 0 1 2 3 4 Dry Skin 0 1 2 3 4 Constipation 0 1 2 3 4 Slow Pulse Rate 0 1 2 3 4 Inability to focus or slow thinking 0 1 2 3 4 Poor memory and concentration 0 1 2 3 4 Depressed Mood 0 1 2 3 4 Lack of interest in activities 0 1 2 3 4 Cortisol Deficiency Symptoms Fatigue, especially in morning 0 1 2 3 4 Energy boost late morning 0 1 2 3 4 Afternoon fatigue, “crash” 0 1 2 3 4 Energy boost after supper / evening 0 1 2 3 4 Dizziness or lightheadedness 0 1 2 3 4 Low blood sugar if not eating frequently 0 1 2 3 4 Shakiness or shaky hands 0 1 2 3 4 Feeling of panic / inability to handle stress 0 1 2 3 4 Inability to focus or slow thinking 0 1 2 3 4 Rage or sudden angry outbursts 0 1 2 3 4 Emotional hypersensitivity 0 1 2 3 4 No patience or easily irritated 0 1 2 3 4 Flu-like symptoms, achey all over 0 1 2 3 4 Headaches 0 1 2 3 4 Difficulty falling asleep 0 1 2 3 4 Night-time awakening 0 1 2 3 4 Stomach Support Symptoms Excessive belching or burping 0 1 2 3 4 Gas immediately following a meal 0 1 2 3 4 Bad breath 0 1 2 3 4 Sense of fullness during and after meals 0 1 2 3 4 Difficulty digesting fruits and vegetables 0 1 2 3 4 Undigested foods in stool 0 1 2 3 4 Pass large amount of foul smelling gas 0 1 2 3 4 More than 3 bowel movements daily 0 1 2 3 4 Frequent use of laxatives 0 1 2 3 4 Difficulty with bowel movement 0 1 2 3 4 Biliary Suppory Symptoms Greasy or fatty foods are bothersome 0 1 2 3 4 Gas / bloating several hours after eating 0 1 2 3 4 Bitter taste in mouth, esp. in morning 0 1 2 3 4 Itchy skin 0 1 2 3 4 Occasional clay colored stools 0 1 2 3 4 Pass large amount of foul smelling gas 0 1 2 3 4 More than 3 bowel movements daily 0 1 2 3 4 Frequent use of laxatives 0 1 2 3 4 History of gallbladder problems or removal 0 1 2 3 4 Intestinal Support Symptoms Fiber and roughage lead to constipation 0 1 2 3 4 Indigestion 2-4 hours after eating 0 1 2 3 4 Fullness 2-4 hours after eating 0 1 2 3 4 Excessive belching or burping 0 1 2 3 4 Pass large amount of foul smelling gas 0 1 2 3 4 Nausea after eating 0 1 2 3 4 Mucous or greasy appearing stools 0 1 2 3 4 Loose stools 0 1 2 3 4 Difficulty losing weight 0 1 2 3 4 Increased thirst and appetite 0 1 2 3 4 Insomnia Questionnaire (IF APPLICABLE) How long have you had a sleep problem? Did it begin after a stressful time? Does insomia run in your family? What time do you lie down to sleep? What time do you fall asleep? How often do you awaken? What times do you awaken? How long until you fall back asleep? Type 1 Serotonin/Melatonin Deficiency Night Owl - Hard to get to sleep 0 1 2 3 4 Disturbed sleep, premature awakening 0 1 2 3 4 Negativity, depression 0 1 2 3 4 Worry, anxiety / Panic attacks / phobias 0 1 2 3 4 Low self esteem 0 1 2 3 4 Obsessive thoughts / behaviors 0 1 2 3 4 Hyperactivity / tics 0 1 2 3 4 Perfectionism, controlling behavior 0 1 2 3 4 Winter blues 0 1 2 3 4 Irritability, rage 0 1 2 3 4 Dislike of hot weather 0 1 2 3 4 Afternoon / evening cravings carbs, alcohol 0 1 2 3 4 Type 2 GABA Deficiency Overstressed and burned out 0 1 2 3 4 Unable to relax / loosen up 0 1 2 3 4 Stiff or tense muscles 0 1 2 3 4 May experience panic attacks 0 1 2 3 4 Respond well to meds, e.g. xanax 0 1 2 3 4 Type 3 High Cortisol “Wired but tired” before bedtime 0 1 2 3 4 Awaken alert “ready to get to work” 0 1 2 3 4 Awaken agitated or hypervigilant 0 1 2 3 4 Awaken startled or shocked feeling 0 1 2 3 4 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 No Have you taken other antibiotics for 2 months or longer, or in shorter course multiple times in a single year? Yes No Have ever you taken a broad spectrum antibiotic? Yes No Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs? Yes No Have you been pregnant? None 1 time 2 times or more Have you taken birth control pills? No For 6 months to 2 years More than 2 years Have you taken steroids, such as prednisone or cortisone? No For 2 weeks or less More than 2 weeks Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke... No reactions Moderate to severe symptoms Mild symptoms Are your symptoms worse on damp, muggy days or in moldy places? Yes No Have 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 symptoms Do you crave sugar? Yes No Do you crave breads? Yes No Do you crave alcoholic beverages? Yes No Does tobacco smoke really bother you? Yes No Total Score for Section A Candida Questionnaire Section 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 9 Feeling of being “drained” 0 3 6 9 Poor memory 0 3 6 9 Feeling “spacey” or “unreal” 0 3 6 9 Inability to make decisions 0 3 6 9 Numbness, burning or tingling 0 3 6 9 Insomnia 0 3 6 9 Muscle aches 0 3 6 9 Muscle weakness or paralysis 0 3 6 9 Pain and/or swelling in joints 0 3 6 9 Abdominal pain 0 3 6 9 Constipation 0 3 6 9 Diarrhea 0 3 6 9 Bloating, belching or intestinal gas 0 3 6 9 Troublesome vaginal burning, itching or discharge 0 3 6 9 Prostatitis 0 3 6 9 Impotence 0 3 6 9 Loss of sexual desire or feeling 0 3 6 9 Endometriosis or infertility 0 3 6 9 Cramps and/or other menstrual irregularities 0 3 6 9 Premenstrual tension 0 3 6 9 Attacks of anxiety or crying 0 3 6 9 Cold hands or feet and/or chilliness 0 3 6 9 Shaking or irritable when hungry 0 3 6 9 Section B Total Candida Questionnaire Section 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 3 Irritability or jitteriness 0 1 2 3 Loss of coordination 0 1 2 3 Inability to concentrate 0 1 2 3 Frequent mood swings 0 1 2 3 Headaches 0 1 2 3 Dizziness or loss of balance 0 1 2 3 Pressure above ears or feeling of head swelling 0 1 2 3 Easy bruising 0 1 2 3 Chronic rashes or itching 0 1 2 3 Psoriasis or recurrent hives 0 1 2 3 Indigestion or heartburn 0 1 2 3 Food sensitivity or intolerance 0 1 2 3 Mucous in stools 0 1 2 3 Rectal itching 0 1 2 3 Dry mouth or throat 0 1 2 3 Rashes or blisters in mouth 0 1 2 3 Bad breath 0 1 2 3 Foot, hair or body odor not relieved by washing 0 1 2 3 Nasal congestion or post nasal drip 0 1 2 3 Nasal itching 0 1 2 3 Sore throat 0 1 2 3 Laryngitis or loss of voice 0 1 2 3 Cough or recurrent bronchitis 0 1 2 3 Pain or tightness in chest 0 1 2 3 Urinary frequency, urgency or incontinence 0 1 2 3 Burning on urination 0 1 2 3 Spots in front of eyes or erratic vision 0 1 2 3 Burning or tearing of eyes 0 1 2 3 Recurrent infections or fluid in ears 0 1 2 3 Ear pain or deafness 0 1 2 3 Section 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.
