New Patient Form | Integrative Medicine Center of Western Colorado

Patient Form

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Patient Information

General Information

First Name*

Middle Initial

Last Name*

Date of Birth*

Month

Day

Year

Social Security*

Used as your unique medical record identifier

Home Telephone*

Work Telephone

Mobile Telephone*

May we text detailed medical related messages?*

Yes

Email*

May we use your email to send medical related messages?*

Yes

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 State ZIP Code

Street Address (if different)

Street Address Address Line 2 City State ZIP Code

Your Occupation:

Your Employer:

Current Physicians / Health Providers

Emergency Contact - Name

Emergency Contact - Telephone

Emergency Contact - Relationship

How 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 Policies

Please 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 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.

Initials

Medicare 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.

Initials

Are you insured by*

Medicare

Medicaid

Neither

Confirmation

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

Year

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):

Do you have any allergies?*

Yes

Allergies

Hormones taken in PAST (dates):

Are you currently on any Medications?*

Yes

Current Medications (dose/frequency) and Supplements including marijuana/CBD products:

Menstrual History (WOMEN only):

Age of first menses:

Date of last menses:

Month

Day

Year

History of abnormal menses?

Yes

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)

Mother:

Father:

Paternal GF:

Paternal GM:

Maternal GF:

Maternal GM:

Siblings:

Social History

Do you smoke or chew tobacco?

Yes

How much per day?

Do you drink alcohol?

Yes

How much per day?

Do you use any other drugs?

Yes

How much per day?

Do you exercise regularly?

Yes

How much per week?

How would you describe your stress level?

Low

Moderate

High

Are you married?

Yes

Do you have kids?

Yes

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 / always

Estrogen 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

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

Comments
This field is for validation purposes and should be left unchanged.

Location

Integrative
Medicine Center

2470 Patterson Rd # 8
Grand Junction, CO 81505

Call or Text: (970) 245-6911

Fax: (970) 255-6443

IMC remedies, nutritional products, and treatment modalities are intended to enhance overall health and are not intended or implied to diagnose, treat, prevent, or cure any specific illness. All remedies and nutritional supplements are only the doctor’s best recommendation and are at no time to be considered a prescription. Always consult with your health practitioner before beginning any treatment program, especially if pregnant or nursing. If you are having a medical emergency, please call 911 or go to nearest emergency room. The information provided here is for educational purposes only and should not be considered medical advice. IMC assumes no responsibility for how this information is used. We do our best to keep all information as current as possible, but medical information can change frequently.

Patient Form

Patient Information

Policies

Health Questionnaire

Family History

Symptoms

Master Symptoms

Quick Links

Categories

Location

Integrative
Medicine Center

Call or Text: (970) 245-6911

Fax: (970) 255-6443

Quick Links

Categories

Location

Integrative
Medicine Center

Call or Text: (970) 245-6911

Fax: (970) 255-6443

Patient Form

Patient Information

Policies

Health Questionnaire

Family History

Symptoms

Master Symptoms

Quick Links

Categories

Location

IntegrativeMedicine Center

Call or Text: (970) 245-6911

Fax: (970) 255-6443

Quick Links

Categories

Integrative
Medicine Center