1 marchionda imaginative medicine institute · covers little more than costly drugs and invasive...

1Marchionda Imaginative Medicine Institute

PATIENT INFORMATION

General Information

Name: __________________________________________

Date of Birth: ____/____/____

Social Security Number: xxx-xx-_____ (Used as your unique medical record identifier)

Home Telephone: (______) ______-________

Work Telephone: (______) ______-________

Mobile Telephone: (______) ______-________

Email Address:

_________________________________________________________________

May we use your email to send medical related messages? ___Yes ___No

(Your email will never be sold. You will only receive emails specific to MIMI.)

Mailing Address:

_______________________________________________________________________

Physical Address (if different):

_______________________________________________________________________

City / State:

_____________________________________________________Zip Code: __________ Emergency Contact:

_____________________________________________________________

Relationship: _______________________________

Telephone: (______) ______-________ Your Occupation:

__________________________________________________________________________

Your Employer:

__________________________________________________________________________ Current Physicians / Health Providers:

Primary Care Provider:

__________________________________________________________________________

Other Providers and Specialists:

__________________________________________________________________________ How did you hear about MIMI

__________________________________________________________________________

mimicares.com – ph# (970) 628-1624 – fax# (970) 628-0068


POLICIES

Notice of Insurance, Billing & Missed Appointment Policies

Please read and initial each section – thank you!

Marchionda Imaginative Medicine Institute (MIMI) does not participate in insurance

plans, nor submit claims, nor complete paperwork for insurance claims.

Initials _________

Payment is due in full at the time of service with cash, check or major credit card.

The returned check charge is $25.

Initials _________

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.

Initials _________

Medicare or Medicaid beneficiaries only:

Dr. Marchionda does see Medicare beneficiaries. Medicare beneficiaries need to see a

Provider that has “opted out” of Medicare, which Dr. Marchionda has done.

Initials _________

Dr. Marchionda can only see Medicaid beneficiaries for “holistic wellness visits” and

cannot act as a Medicare patient’s primary care provider.

Initials _________

I, or my legal representative, agree not to submit a claim, nor ask the practitioner to

submit a claim, to Medicare or Medicaid for items or services, even if such items or

services are otherwise covered by Medicare.

Initials _________

I have read the above policy information and by signing below agree to the terms

outlined.

Signature ______________________________________________ Date ____/____/____



Marchionda Imaginative Medicine Institute – MIMI’s Clinic New Patient Packet

1

Name: _____________________________________ Date: _____________________ What are the primary health conditions that you would like to address?

1)_________________________________ 2)__________________________________

3)_________________________________ 4)__________________________________ How long have you suffered with these conditions? 1. _________ 2. _________ 3. __________ 4. _________ Do you have any other health conditions that you would like help with?

_______________________________________________________________________ What have you tried doing to resolve your health conditions that Did Not work? ________________________________________________________________________ How often are you discouraged about your health? Always/ Never/ Sometimes How do these conditions interfere with the following areas in your life?

Happiness Kids Marriage/Relationships Sleep Freedom Memory

Finances Time Work Family Hobbies Life Libido Goals Other ________________________________________________________________ Do you know how this (these) conditions may have started?

________________________________________________________________________

How have you taken care of your health in the past? Medications Acupuncture/PT/Chiro Routine Medical Exercise Diet and Nutrition

Holistic Vitamins

Other: _______________

How did the previous methods work for you?

_____________________________________________________________________


MIMI’s Clinic New Patient Packet

2

Are there any health conditions you are afraid this might turn into?

________________________________________________________________________ ________________________________________________________________________

Autoimmunity Weight gain Heart disease Depression Surgery Arthritis

Cancer Diabetes Alzheimer’s/Dementia Genetic Variances

Other: _____________

What would be improved with better health?

Less Stress More Energy Self-Esteem Confidence Goals Purpose

Where do you picture yourself in the next 3-5 years if this problem is not taken

care of? Please be specific: ______________________________________________

_______________________________________________________________________

Are there any of the “6 Key Pillars of Health” that you would like help with?

#1 Digestive Health and Genetic Understanding #2 Balanced Hormones and Emotions #3 Nutritional Correction for Living to be 120 #4 Improved Fitness, Happiness and Lifestyle #5 Optimal Brain Function and Memory #6 Joint Health and Pain Resolution

Are you here visiting us to:

a) Resolve my immediate problem b) Lifestyle program for optimized living c) Stem cell therapy d) All of the above Other: _____________________________

What potential obstacles do you foresee that would prevent you to get the help you deserve? _______________________________________________________________________



3

Is it possible to overcome or prevent these potential barriers? _______________________________________________________________________ If we were to sit down and discuss your life 3 years from now and look back at today, what would you like to experience for you to be happy with your progress and feel like this was the most impactful health transformation possible? (This can relate to your relationships, your freedom, personal capabilities, your work, etc.) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ In helping thousands of patients just like you we have found that there are 8 mindsets that will best assist you in accomplishing your health goals. Please rate yourself on each mindset with 0% meaning, not you at all and 100% as you totally agree or you would like to have that mindset. #1 Restoring your health is your top priority and you are committed to do what it takes to start feeling better.

0% 25% 50% 75% 100% #2 Your life is a gift and you are confident that your body can heal with correct testing, treatments, lifestyle, coaching and guidance.

0% 25% 50% 75% 100% #3 You are willing to make the necessary lifestyle changes for you to achieve your goals once you have the support to lead you in the right direction.

0% 25% 50% 75% 100% #4 You are 100% committed to working with a healthcare team that focuses more on prevention and optimizing your health than on disease and medication management and wish to live a long, healthy, happy life.

0% 25% 50% 75% 100% #5 You are driven to feel great and to meet your health goals because your family, friends, co-workers, and loved ones believe in you and support you.

0% 25% 50% 75% 100%



4

#6 You see that investing in health leads to a healthier future because without your health, everything else in life loses its enjoyment and your insurance usually covers little more than costly drugs and invasive surgery.

0% 25% 50% 75% 100% #7 You understand that healing is a holistic process that involves emotional well-being, physical fitness, mental enhancement, detoxification, and are excited to share your breakthroughs with your friends and family.

0% 25% 50% 75% 100% #8 You feel you can learn how to be your own best healer and would like a sim-ple, step-by-step approach that gives you an educational curriculum so that you can get healthy and keep your health independence for the rest of your life.

0% 25% 50% 75% 100% Anything else you feel we should know about you? _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Provider Recommendations/Notes: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Thank You For Your Commitment To Your Health!


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

WOMEN only - Check if you have ever

had:

___ Abnormal mammogram

___ Abnormal pap smear

___ Abnormal vaginal bleeding

___ Breast cancer

___ Cervical cancer

___ Fibrocystic breasts

___Ovarian cysts

___ Uterine cancer

___ Uterine growths

___ Uterine infections

MEN only - Check if you have ever had:

___ Enlarged prostate

___ Mumps

___ Prostate cancer

___ Prostate infections

___ Testicle infection

___Vasectomy

___ Other / Explain: ________________________________________________________

__________________________________________________________________________

__________________________________________________________________________



Health Questionnaire (continued...)

Surgeries (dates):

__________________________________________________________________________

__________________________________________________________________________

Allergies (drug, food, seasonal, etc.):

__________________________________________________________________________

__________________________________________________________________________

Current Medications (dose/frequency) and Supplements:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Hormones taken in PAST (dates):

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

WOMEN only - Menstrual History:

Age of first menses: _____ Date of last menses: ____/____/________

History of abnormal menses? _______ Explain:

________________________________________________________________________

Date of last pap smear: ____/____/____ Date of last mammogram: ____/____/____



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: _______________________________________________________________

Maternal GF: _______________________________________________________________

Maternal GM: ______________________________________________________________

Siblings: ___________________________________________________________________

Health Questionnaire (continued…

Social History

Do you use tobacco? ______ How much per day? ______

Do you drink alcohol? ______ How much per day? ______

Do you exercise regularly? ______ How much per week? ______

What is your primary concern? ________________________________________________

When did this start? _________________________________________________________

What are your GOALS for your consultation?

__________________________________________________________________________

__________________________________________________________________________



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

Ears/Nose:

___ Nasal congestion

___ Nasal discharge

___ Bloody nose

___ Sinus trouble or pain

___ Decreased hearing

___ Ringing in ears

___ Ear pain or drainage

Eyes:

___ Change in vision

___ Sudden loss or decrease in vision

___ Double or blurry vision

___ Redness

___ Infection

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

Health Questionnaire (continued...)

Skin:

___ Rash

___ Lesion or unusual mole

___ Recent change in mole size/color/

shape

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

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

Bladder:

___ Burning with urination

___ Urinating frequently

___ Get up at night to urinate

___ Recurrent bladder infections

___ Slow start of urine flow or dribbling

___ Loss of urine with cough or strain

___ Brown or pink urine

Muscular:

___ Aching or stiff muscles

___ Pain in muscles

Nerves:

___ Numbness

___ Tingling

___ Weakness in extremities

___ Loss of balance

___ Loss of coordination

___ Tremor

___ Shaking

___ Paralysis

___ Smell or taste change

Bone:

___ Bone or joint swelling or stiffness

___ Back pain

___ Neck pain

Blood:

___ Easy bruising

___ Easy bleeding

___ Blood clots

___ Varicose veins

___ Pain in calves when walking

Mental:

___ Anxiety

___ Feeling blue or sad

___ Moodiness

___ Memory loss

___ Sleep disturbance

___ Thoughts of suicide

___ Difficulty with sex

___ Family/marital difficulties

___ Trouble with alcohol/drugs

Female:

___ Abnormal periods

___ Bleeding between periods

___ Trouble with periods

___ Vaginal discharge, itch or odor

___ Breast pain, swelling or lumps

___ Nipple discharge

___ Sexual difficulties

Male:

___ Sexual difficulties

___ Discharge from penis

___ Testicular pain, swelling or lump


Name: ___________________________________________ Age: ______ Sex: _____ Date: ____________________ PART I Please list your 5 major health concerns in order of importance:1. ____________________________________________ 4. ___________________________________________ 2. ____________________________________________ 5. ___________________________________________3. ____________________________________________

PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Metabolic Assessment Formtm

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

Category I Feeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue Pass large amount of foul-smelling gasMore than 3 bowel movements daily Use laxatives frequently

Category II Increasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swellingFrequent bloating and distention after eating Category III Intolerance to smellsIntolerance to jewelryIntolerance to shampoo, lotion, detergents, etcMultiple smell and chemical sensitivitiesConstant skin outbreaks Category IV Excessive belching, burping, or bloatingGas immediately following a mealOffensive breathDifficult bowel movementsSense of fullness during and after mealsDifficulty digesting proteins and meats; undigested food found in stools

Category VStomach pain, burning, or aching 1-4 hours after eatingUse of antacidsFeel hungry an hour or two after eatingHeartburn when lying down or bending forwardTemporary relief by using antacids, food, milk, or carbonated beveragesDigestive problems subside with rest and relaxationHeartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category VI Difficulty digesting roughage and fiberIndigestion and fullness last 2-4 hours after eatingPain, tenderness, soreness on left side under rib cageExcessive passage of gasNausea and/or vomitingStool undigested, foul smelling, mucus like, greasy, or poorly formedFrequent loss of appetite

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 3

Category VIIAbdominal distention after consumption of fiber, starches, and sugarAbdominal distention after certain probiotic or natural supplementsDecreased gastrointestinal motility, constipationIncreased gastrointestinal motility, diarrheaAlternating constipation and diarrheaSuspicion of nutritional malabsorptionFrequent use of antacid medicationHave you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?

Category VIII Greasy or high-fat foods cause distressLower bowel gas and/or bloating several hours after eatingBitter metallic taste in mouth, especially in the morningBurpy, fishy taste after consuming fish oilsUnexplained itchy skinYellowish cast to eyesStool color alternates from clay colored to normal brownReddened skin, especially palmsDry or flaky skin and/or hairHistory of gallbladder attacks or stonesHave you had your gallbladder removed?

Category IX Acne and unhealthy skinExcessive hair lossOverall sense of bloatingBodily swelling for no reasonHormone imbalancesWeight gainPoor bowel functionExcessively foul-smelling sweat

Category XCrave sweets during the dayIrritable if meals are missedDepend on coffee to keep going/get startedGet light-headed if meals are missedEating relieves fatigueFeel shaky, jittery, or have tremorsAgitated, easily upset, nervousPoor memory, forgetful between mealsBlurred vision

Category XIFatigue after mealsCrave sweets during the dayEating sweets does not relieve cravings for sugarMust have sweets after mealsWaist girth is equal or larger than hip girthFrequent urinationIncreased thirst and appetiteDifficulty losing weight

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

Category XII Cannot stay asleepCrave saltSlow starter in the morningAfternoon fatigueDizziness when standing up quicklyAfternoon headachesHeadaches with exertion or stressWeak nails

Category XIIICannot fall asleepPerspire easilyUnder a high amount of stressWeight gain when under stress Wake up tired even after 6 or more hours of sleepExcessive perspiration or perspiration with little or no activity

Category XIV Edema and swelling in ankles and wristsMuscle crampingPoor muscle enduranceFrequent urinationFrequent thirstCrave saltAbnormal sweating from minimal activityAlteration in bowel regularityInability to hold breath for long periodsShallow, rapid breathing

Category XVTired/sluggishFeel cold―hands, feet, all overRequire excessive amounts of sleep to function properlyIncrease in weight even with low-calorie dietGain weight easilyDifficult, infrequent bowel movementsDepression/lack of motivationMorning headaches that wear off as the day progressesOuter third of eyebrow thinsThinning of hair on scalp, face, or genitals, or excessive hair lossDryness of skin and/or scalpMental sluggishness

Category XVIHeart palpitationsInward tremblingIncreased pulse even at restNervous and emotionalInsomnia

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3 0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Category XVI (Cont.) Night sweatsDifficulty gaining weight

Category XVII (Males Only)Urination difficulty or dribblingFrequent urinationPain inside of legs or heelsFeeling of incomplete bowel emptyingLeg twitching at night

Category XVIII (Males Only)Decreased libidoDecreased number of spontaneous morning erectionsDecreased fullness of erectionsDifficulty maintaining morning erectionsSpells of mental fatigueInability to concentrateEpisodes of depressionMuscle sorenessDecreased physical staminaUnexplained weight gainIncrease in fat distribution around chest and hipsSweating attacksMore emotional than in the past

Category XIX (Menstruating Females Only)PerimenopausalAlternating menstrual cycle lengthsExtended menstrual cycle (greater than 32 days)Shortened menstrual cycle (less than 24 days)Pain and cramping during periodsScanty blood flowHeavy blood flowBreast pain and swelling during mensesPelvic pain during mensesIrritable and depressed during mensesAcneFacial hair growthHair loss/thinning

Category XX (Menopausal Females Only)How many years have you been menopausal?Since menopause, do you ever have uterine bleeding?Hot flashesMental fogginessDisinterest in sexMood swingsDepressionPainful intercourseShrinking breastsFacial hair growthAcneIncreased vaginal pain, dryness, or itching

PART IIIHow many alcoholic beverages do you consume per week? How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times do you eat raw nuts or seeds per week?List the three worst foods you eat during the average week:List the three healthiest foods you eat during the average week:PART IVPlease list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Rate your stress level on a scale of 1-10 during the average week:How many times do you eat fish per week?How many times do you work out per week?

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

1 marchionda imaginative medicine institute · covers little more than costly drugs and invasive...

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