Step 1 of 4 25% 1731 Boyson Road, Hiawatha, IA 52233(319) 363-0033DEMOGRAPHIC PROFILE Please complete to the best of your knowledge.Today's Date* MM slash DD slash YYYY First Name* Last Name* Email* Phone*Date of Birth* MM slash DD slash YYYY Sex* Male Female Height Weight Address* Street Address Address Line 2 (optional) City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you filling this form out for a minor?*(someone under the age of 18) Yes No Legal Guardian First Last Relationship to patient Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneName of Insurance Policy Holder's Name Insurance Policy / Card # Primary Care Provider PhoneFax Alternative Providers (i.e. Chiropractor) PhonePreferred Pharmacy PhonePlease list your raceChooseWhiteAsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOtherUnreported/Refused to ReportEthnicity Hispanic or Latino Not Hispanic or Latino Employment Status Employed Not Employed Retired Occupation COMPREHENSIVE HEALTH INFORMATIONReferring Provider (if applicable) PhoneFax How did you hear about us?(If recommended by a current patient, please state who so we can send them a token of our appreciation!)History of Present IllnessWhen listing your history below, please prioritize and score their severity on a scale of 0-10 with 0 being non-bothersome and 10 being the worst imaginable. We may not have time to discuss everything in the first visit so prioritizing will assist us in addressing your most important issues during your initial visit. Please list in this format: Illness | Score | Approximate time it started Use a new line for each illness.Is there anything that makes these problems better or worse?Past Medical History Alzheimer’s Anemia Anxiety Arthritis Asthma Back Injury Bladder tumor Bleeding problems BPH Bronchitis Cancer Cataracts Celiac Chest Pain Constipation COPD Cysts (ovarian) Depression Diabetes Diverticulitis Dysmenorrhea Endometriosis Falls Fertility problems Fibroids Fractures Glaucoma Headaches Head Injury Heart attack Heart disease Hemorrhoid HIV/AIDS Hypertension Thyroid Disease Incontinence Irritable bowel Kidney stones Liver disease Mental health Multiple sclerosis Osteoporosis Parkinson’s PCOS Pneumonia Prolapse vaginal Prostate issues Pulmonary emboli Renal disease Sinusitis Skin sensitivities Spinal cord injury STDs Stroke Seizures Vascular problems Heart murmur Urinary Infection Other If you checked cancer above, please let us know what type of cancer you had. Other? Please list: Past Surgical History Bladder suspension C-section Cataracts Cardiac related Hemorrhoids Hysterectomy Joint replacement Ovaries removed Pacemaker Polyps Other Other? Please list: Immunization History Polio Tetanus MMR Pertussis Diphtheria Meningitis Influenza Gardisil BCG for TB Hepatitis B Pneumonia I prefer to not be vaccinated If you selected Tetanus, Influenza, and/or Pneumonia, what year did you receive these vaccinations?List vaccine and then year. Enviromental AllergiesFood AllergiesDrug AllergiesPlease list an example of what you eat for breakfastPlease list an example of what you eat for lunchPlease list an example of what you eat for dinnerHow many ounces of water do you drink daily? Current MedicationsPlease list Medication, Dosage, Frequency, and Who prescribed it.Do you currently have an intrauterine device (IUD)? Yes No Current Nutritional/Herbal Supplements-Please bring supplements or a copy of the Ingredients to your visitPlease list Supplement, Dosage, Frequency, and Who prescribed it.Social History Do you smoke? History of smoking? Do you consume caffeine? Do you exercise? Do you drink alcohol? Do you have amalgam, silver, or gold fillings? Metal dental fillings removed? Marijuana Live alone Other drugs Married Employed Unemployed Occupational exposures (toxins) Disabled How many packs do you smoke per day? When did you quit smoking? How many times per day do you consume caffeine? How many times do you exercise per week? On average, how many hours do you sleep per night? How were you delivered as a baby?* Vaginal Delivery Cesarean Delivery Were you breastfed as a child for over 6 months?* Yes No Have you taken numerous rounds of antibiotics in your life?* Yes No If you have taken antibiotics, for what and how long? Have you had past exposure to water damaged buildings containing mold? Yes No Not Sure Do you have current exposure to water damaged buildings containing mold? Yes No How would you rank your stress from 0-10 with 10 ranking the highest? Do you have history of any significant tick/bug bites? Yes No Have you had any of these in the past year? Vision Check Dental Visit Yearly Exams Pap Mammogram In the past 10 years? Bone Density Scan Colonoscopy EKG Last lab work Perform breast self-exams Perform testicular self-exams What year did you have the Bone Density Scan? What year did you have the Colonoscopy? What year did you have the EKG? What year did you have your last lab work? REVIEW OF SYSTEMS Check all that apply.Constitutional Fevers Hot flashes Fevers Night sweats Chills Fatigue Problems falling asleep Problems staying asleep Weight loss Weight gain Appetite change Head/Eyes Contact lenses Glasses Vision loss Excessive tears Dry eyes Irritation Itching Blurring Double vision Discharge Light sensitivity Ears, Nose, Throat Otalgia-ear pain Otorrhea-drainage Hearing loss Ringing in ears Nasal polyps Nose bleed Sinus tenderness Congestion Postnasal drip Neck stiffness Hoarseness Sore throat Issues swallowing Dentures Mouth sores Bleeding gums Cardiac Chest pain Palpitations Irregular beat Murmur Fainting History of Rheumatic Fever Edema (swelling) Shortness of breath with activity Vascular Varicose Veins Claudication Raynaud’s Respiratory Cough Cough produces mucous Wheezing Shortness of Breath Wear oxygen Wear BI/CPAP Color of mucous? Amount of mucous? Gastroinstestinal Constipation Hemorrhoids Diarrhea Nausea Vomiting Changes in bowel pattern Epigastric pain Abdominal pain Blood in stool Flatulence Pain right upper Pain right lower Pain left upper Pain left lower Ulcers Belching Food intolerances Reflux Hernia Genitourinary Hesitancy Frequency Urgency Painful Urination Blood in Urine Excessive Urination Leakage of urine Number of urinations at night Musculoskeletal Back Pain Joint pain Joint Swelling Muscle weakness Cramping Muscle Stiffness Muscle Pain Gout Limited ROM Dermatology Acne Birthmarks Rashes Itching Dryness Scars Ulcers Suspicious lesions Mole Changes Neurological Headache Dizziness Lightheadedness Weakness Head Spinning Nerve Pain Seizures Tremor Memory loss Endocrine Heat Intolerance Cold Intolerance Excessive urination Hair changes Nail changes Goiter Hematology Bruise easily Swollen lymph nodes Psych: How do you describe your mood? Pleasant Depressed Anxious Panic easily PTSD Pain: If you have pain, what is the location of your pain? On a scale of 0-10 with 10 being the worst pain imaginable and 0 being no pain, rank your pain. What is the frequency of your pain? No pain Sometimes 50% of the time Frequently Constant Female Breast lumps Breast tenderness Nipple discharge Decreased libido Vaginal dryness Vaginal discharge Vaginal bleeding Vaginal sores Painful cycles Pelvic pain Abnormal PAP Abnormal mammogram Pregnancy Miscarriage On birth control STD's PMS symptoms in second half of cycle Number of pregnancies? Number of miscarriages? If currently taking birth control, which kind and how long have you been on it? Have you had a hysterectomy? Yes No Were your ovaries removed? Have you taken hormone replacement therapy (HRT)? Yes No Which kind? Please check the routes that you have taken of HRT Oral pills Patch Gel/cream Sublingual troche Vaginal ring Your age when you began menopause? Year you began menopause? Any other information we should know?Male Testicular mass Testicular pain Erectile dysfunction Decreased libido Penile sores Change in urine stream Prostate problems STD's Penile discharge Any other information we should know? FAMILY MEDICAL HISTORY List any family relations that have had a history of the diseases below. For example, if your grandmother on your mother’s side had diabetes, find diabetes in the list below, then click on "Choose One" and then select “Maternal Grandmother”.Alzheimer’sChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildAnemiaChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildAsthmaChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildOsteoarthritisChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildCeliac DiseaseChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildDepressionChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildDiabetesChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildEpilepsyChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildGlaucomaChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildHeart DiseaseChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildHigh Blood PressureChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildInfertilityChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildLiver DiseaseChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildMental IllnessChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildOsteoporosisChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildStrokeChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildTuberculosisChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildAutoimmune DiseaseChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildHypothyroidChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildMultiple SclerosisChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildPsoriasisChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildRheumatoid ArthritisChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildCancerChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildBreast CancerChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildColon CancerChoose OneFatherPaternal GrandfatherPaternal GrandmotherGreat Paternal GrandfatherGreat Paternal GrandmotherPaternal UnclePaternal AuntPaternal Male CousinMotherMaternal GrandfatherMaternal GrandmotherGreat Maternal GrandfatherGreat Maternal GrandmotherMaternal UncleMaternal AuntMaternal Male CousinBrotherSisterChildOvarian CancerChoose OnePaternal GrandmotherGreat Paternal GrandmotherPaternal AuntMotherMaternal GrandmotherGreat Maternal GrandmotherMaternal AuntSisterChildProstate CancerChoose OneFatherPaternal GrandfatherGreat Paternal GrandfatherPaternal UnclePaternal Male CousinMaternal GrandfatherGreat Maternal GrandfatherMaternal UncleMaternal Male CousinBrotherChildPCOS (Polycystic Ovary Syndrome)Choose OnePaternal GrandmotherGreat Paternal GrandmotherPaternal AuntMotherMaternal GrandmotherGreat Maternal GrandmotherMaternal AuntSisterChildCheck this box if you have double checked that all relevant information has been completed and you are ready to submit the form.* Yes, I have completed all the relevant information.
