New Patient

It is our hope that we can assist you with your current and future health concerns. During the course of your examination and treatments, please feel free to comment, ask questions, and provide us with feedback. We feel that the more you know and understand about yourself, the more effective your treatments will be. We look forward to helping you achieve optimal health and well-being.

Please remember to wear stretchy, comfy clothes to your appointment.

New Patient Form

The following patient information is required.

Male Female
Current Previous
Yes No
Yes No
Yes No
Yes No
Health History

C = Current P = Previous O = Occasionally N = Never

C

P

O

N

CARDIOVASCULAR

Angina

Bleeding disorders

Ankle swelling

Heart disease

Heart murmur

High blood pressure

Irregular heartbeat

Low blood pressure

Pacemaker

Poor circulation

Stroke


C

P

O

N

SKIN

Bruise easily

Bleed easily

Dryness

Eczema

Itching

Psoriasis

Rashes

Sensitivities

Varicose veins


C

P

O

N

INFECTIONS

AIDS

Hepatitis

Herpes

HIV

Infectious skin conditions

Tuberculosis

C

P

O

N

EYE, EAR, NOSE AND THROAT

Difficulty swallowing

Earache

Hearing Loss

Hoarseness

Nosebleeds

Ear noises

Sinus pain

Vision problems


C

P

O

N

MEN

Decreased urinary flow

Dribbling after urination

Erectile dysfunction

Waking up to urinate

Inability to control bladder


C

P

O

N

WOMEN

Backache

Breast problems

Bladder dysfunction

Caesarian section

Cramps

Fibroids

Menopausal symptoms

Mid cycle pain

Ovarian cysts

Painful intercourse

Painful menstruation

Pregnancy*

PMS

Yeast infection

C

P

O

N

GENERAL

Alcohol/drug problem

Allergies

Arthritis

Blood in urine

Cancer

Constipation

Convulsions/Seizures

Diabetes

Digestive problems

Dizziness

Esophageal reflux

Fainting

Fatigue

Fibromyalgia

Gall bladder problems

Headache

Hernia

Insomnia/sleep problems

Kidney problems

Liver problems

Mental disorders

Nervousness/depression

Neuralgia

Osteoporosis

Spinal curvature


C

P

O

N

RESPIRATORY

Apnea

Asthma

Chronic cough

Difficult breathing

Snoring

 

Matrix Wellness Solutions will not share your information with anyone else, without your prior written consent.
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