General Medicine Homeopathy, P.C.
Ronald D. Whitmont, M.D., DABIM, DABHM
Classical Homeopathic Medicine
250 West 49th Street, Suite 501, New York, NY
(845) 876-6323, Fax: (845) 876-2627
www.homeopathicmd.com
Personal Data:
Name: ______
Address: ______
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Telephone Number (Home):______(Work): ______
Cell Phone: ______Email Address: ______
Birth Date: ______Referred By: ______
Primary Care Doctor:______
Specialist Physician(s): ______
______
Do you have Medicare? Please check yes or no: _____Yes _____No
Occupation: ______
Name of Partner: ______
Occupation of Partner: ______
Medical History:
Allergies: ______
Medications:
Name: Dosage: Frequency:
1. ______
2.______
3.______
4.______
5.______
6.______
Vitamins or Supplements: ______
Others: ______
Tobacco use: YES/NO Drug use: YES/NO Alcohol use: YES/NO Coffee use: YES/NO
Do you Exercise Regularly: YES/NO Type: ______
Any Recent Foreign Travel: YES/NO Where: ______
In The Event of An Emergency, Please Notify:
Name: ______Phone: ______
Number of Children: ______
Members of Household:
Name: Age: Relationship:
______
______
______
______
______
Pets: ______
What health problems are you particularly concerned about? :
______
______
______
______
Do you have any significant work or occupational exposure history: YES/NO
To what agents: ______
Significant childhood illnesses: ______
Significant Injuries: ______
Continued…………
Medical Illnesses/ Injuries:
Head: ______Bladder/ Kidneys: ______
Eyes: ______Stomach: ______
Ears: ______Intestines: ______
Nose/ Sinuses: ______Colon: ______
Mouth: ______Bones/ Joints: ______
Throat: ______Genitals: ______
Lungs: ______Nerves: ______
Heart: ______Skin: ______
Joints: ______Blood: ______
Mental/ Emotional: ______Sexually transmitted: ______
Infectious: ______Cancer: ______
Nutritional: ______Endocrine: ______
Other: ______
Hospitalizations: ______
Surgery: ______
Current Emotional Stressors: ______
Significant Current Life Events: ______
Dietary Restrictions: ______
History of Abnormal Laboratory or Radiologic Findings: ______
Significant FAMILY Medical History:
Mother: ______Father: ______
Siblings: ______
Other: ______
I understand that I am financially responsible for all charges to me, including any balance remaining after any payment of possible insurance benefits.
Signed: ______Date: _____/______/______
Form Revised 4/07