Tell me about yourself and your medical history in advance of your new patient appointment. Use the questions below as a guide, print them out, or fill in the boxes below, and hit "Submit". Alternatively write up your answers in an online document, send me an email with all the information included, or fax the information to me at 1-866-657-5035. This will be a very big help, and will give us a great "head start" during your first visit with me. Thank you!
Patient Name:
Address:
City: State: Zip:
Phone: Birth Date:
Cell phone: Marital: S/M/D
Email address:
List and describe your medical concerns briefly below:
If you experience any PAIN, please describe it's location, nature, and how long it has been a problem:
List and describe what medications you are taking now:
List your vitamins and other over the counter medications:
Are you involved in any legal or monetary proceedings related to your illness? Enter "NO" or if YES, please specify:
Please describe any significant past illnesses or surgeries which you have had:
Please list the other types of doctors or practitioners you have consulted for your current health concerns:
Please describe your dietary habits in general. You might include a typical day's menu of three meals:
Do you use tobacco, alcohol, caffeine in any form, or sugar products like carbonated beverages or desserts? Y/N
Do you have any questions that you would like to ask at this time?
Thank you so much for taking the time to complete this preliminary medical and historical information. It will help us tremendously when the time comes for you to come in for your first consultation. I know that it takes a special kind of person to look beyond conventional wisdom and take a different approach towards your health concerns, and I appreciate your confidence in me. I take my responsibility for making sure that you are very well pleased with your decision very seriously. Although I try hard to accept only patients I am confident that I can help, I cannot guarantee a good fit between doctor and patient. So, if after we have met, you find that I am not the doctor you were looking for, or if I feel that I will not be able to help you or to work comfortably with you, there will be no charge for the (abbreviated) initial consultation. I hope that this policy will encourage those who may not be sure about taking a natural medicine approach to their health concerns to come in for that initial consultation so we can talk, get to know each other, and explore your options. When you do come for your first vist, please bring copies of any and all medical records and laboratory test results with you. It makes things much easier, and we'll get more done that first visit. Also, if you have pain problems, be sure to bring the radiologist readings of your scans or X-rays rather than the films or CD's themselves.
Pursuing natural medicine care is different than what most people are accustomed to, so please take a moment to read my "Consent For Natural Medicine Treatment" form that I posted at the bottom of the "SERVICES" tab on this web site. I look forward to a challenging, productive, and exciting partnership with you as you reach out for optimal health!
Robert C. Filice, MD
