Welcome to Michigan Medicine
Domino’s Farms Family Medicine
Integrative Family Medicine
24 Frank Lloyd Wright Drive
Suite 2300, Lobby H
Ann Arbor, MI 48106-5795
You have scheduled an appointment with Integrative Family Medicine and we are enclosing a number of forms for you to complete prior to your appointment.
This will assist us in working with you toward meeting your goals and developing a well-rounded plan to address your health concerns.
If you are already a patient at Michigan Medicine, we have access to your medical information records and will review your medical history prior to your visit and will take that plus the information requested below to assist you during your visit.
Please bring any current medications or supplements (the actual containers) you are taking with you to your first visit.
It is necessary for you to call the UMHS Registration line, to register, or update your registration, prior to your scheduled appointment time. The telephone number(s) to register and/or update your information is (734) 936-4990, or toll free at 1-866-452-9896. Please advise them that you have an appointment at Integrative Family Medicine.
If you are a new patient to our clinic, we ask that you arrive20 minutes before your scheduled appointment time in order to fill out any necessary paperwork. If you are not able to arrive on time for your scheduled appointment, please call to let us know, we may ask you to reschedule. Please arrive early for your appointment so that the necessary paperwork and intake procedures can be completed and you can benefit from the full time of your appointment. We also request that you do not change the amount of time scheduled for your session.
It is important for you to notify us as soon as possible if it is necessary to reschedule or cancel your appointment time.
If you have any questions regarding your appointment, or regarding this letter, please feel free to contact us at Domino’s Family Medicine, Integrative Family Medicine (734) 647-5640.
Thank you, we look forward to seeing you.
Greg Shumer, MD
Jill Schneiderhan, MD
Carissa Orizondo, MD
FROM I-96:
Take I-96 west to M-14. Take M-14 to US-23 South. Take US-23 South to Plymouth Road exit (exit 41). Turn Left on Plymouth Road to Earhart Road. Turn Left on Earhart Road. In approximately ½ mile, turn Left on Frank Lloyd Wright Drive. Park and enter at Lobby H.
FROM I-696:
Take I-696 west to I-275 South. Take I-275 South to M-14 West. Take M-14 to US-23 South. Take US-23 South to Plymouth Road exit (exit 41). Turn Left on Plymouth Road to Earhart Road (1/4 mile). Turn Left on Earhart Road. In approximately ½ mile, turn Left on Frank Lloyd Wright Drive. Park and enter at Lobby H.
FROM I-94 WEST: (DETROIT AREA)
Take I-94 to US-23 North. Take US-23 North to Plymouth Road exit (exit 41). Turn Right onto Plymouth. Turn Left on Earhart Road. In approximately ½ mile, turn Left on Frank Lloyd Wright Drive. Park and enter at Lobby H.
FROM I-94 EAST: (JACKSON AREA)
Take M-14 East to US-23 South. Take US-23 South to Plymouth Road exit (exit 41). Turn Left on Plymouth Road to Earhart Road (1/4 mile). Turn Left on Earhart Road. In approximately ½ mile, turn Left on Frank Lloyd Wright Drive. Park and enter at Lobby H.
From M-14:
Take M-14 to US-23 South. Take US-23 South to Plymouth Road exit (exit 41). Turn Left on Plymouth Road to Earhart Road (1/4 mile). Turn Left on Earhart Road. In approximately ½ mile, turn Left on Frank Lloyd Wright Drive. Park and enter at Lobby H.
Michigan Medicine Integrative Medicine Clinic
Name: ______Date of birth: ______
What are your goals for this visit? You may also briefly describe your health history. ______
______
______
______
______
Prioritize your most important health concerns today?
ConcernExample: Headache / Onset
June 1978 / Frequency
4 times/Week / Severity
mild/moderate/severe
1.
2.
3.
4.
5.
6.
What prior experiences have you had with alternative or complementary medicine? ______
______
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Use this circle to help you think about yourwhole health.
● All areas are important and connected.
● The body and mind have strong healing abilities.
● Improving one area can help other areas.
● The inner circle represents your values and aspirations.
Your care focuses on you as a unique person.
● Mindful awareness is being tuned in and present.
● Your self-care and everyday choices make up the
next ring.
● The third ring is professional care (tests, medications,
supplements, surgeries, examinations, treatments, and
counseling). This section includes complementaryapproaches like acupuncture and yoga.
● The outer ring includes the people and groups who
make up your community.
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Rate where you feel you are on the scales below from 1-5, with 1 being miserable and 5 being great.
Question / ResponsePhysical Well-Being: / 1
Miserable / 2 / 3 / 4 / 5
Great
Emotional/Mental Well Being: / 1
Miserable / 2 / 3 / 4 / 5
Great
Life: How is it like to live your day-to-day? / 1
Miserable / 2 / 3 / 4 / 5
Great
Where You Are and Where You Would Like to Be
For each area below, consider “Where you are” and “Where you want to be”. Write in a number between 1 (low) and 5 (high) that best represents where you are and where you want to be. The goal is not to be perfect in all areas. You do not need to be a “5” in any of the areas now, nor even wish to be a “5” in the future.
Area of Whole Health / Where I am Now (1-5) / Where I Want to Be (1-5)Working the Body: “Energy and Flexibility” Moving and doing physical activities
like wheeling, walking, dancing, gardening, sports, lifting weights, yoga, cycling,
swimming, and working out in a gym.
Recharge: “Sleep and Refresh” Getting enough rest, relaxation, and sleep.
Food and Drink: “Nourish and Fuel” Eating healthy, balanced meals with plenty of
fruits and vegetables each day. Drinking enough water and limiting sodas, sweeteneddrinks, and alcohol.
Personal Development: “Personal life and Work life” Learning and growing.
Developing abilities and talents. Balancing responsibilities where you live, volunteer,and work.
Family, Friends, and Co-Workers: “Relationships” Feeling listened to and
connected to people you love and care about. The quality of your communication
with family, friends and people you work with.
Spirit and Soul: “Growing and Connecting” Having a sense of purpose and meaning in your life. Feeling connected to something larger than yourself. Finding strength indifficult times.
Surroundings: “Physical and Emotional” Feeling safe. Having comfortable, healthy spaces where you work and live. The quality of the lighting, color, air, and water. Decreasing unpleasant clutter, noises, and smells.
Power of the Mind: “Relaxing and Healing” Tapping into the power of your mind
to heal and cope. Using mind-body techniques like relaxation, breathing, or guided
imagery.
What do you live for? What matters to you? Why do you want to be healthy? Are there any areas you would like to work on? Where might you start? Write a few words to capture your thoughts: (feel free to use back)
______
______
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PERSONAL MEDICAL HISTORY
You will be asked to fill out further paperwork when you arrive at the clinic which will update all of your past medical problems.
REVIEW OF SYMPTOMS
/ Please check the following conditions which apply to you, if a choice is given, please circle the appropriate one.Abuse, personal history of physical or sexual abuse / Pneumonia
Blood Clots, Location(s): / Prostate problems
Digestive issues / Radiation Treatments
Chemical sensitivity / Rheumatic Disease
Chronic Pain, Location(s): / Rheumatic Fever
Kidney Infection/ Stones / Disability, From:
Blood in Stool, Type: / Serious Injury or Accident
History of Infertility / Sexually Transmitted Disease (Chlamydia, Warts, Herpes), Specify other:
Easy Bleeding / Skin Disease, Type(s):
Fatigue / Suicide Attempt
Frequent Sinusitis / Cold hands and feet
Gall Bladder Trouble / Feeling Cold
Eating Disorder / Urinary Difficulties
Hay Fever, Allergy / Vision Problems
Hearing Loss / Ear Problems
Heart Arrhythmia, Type: / Constipation
Eczema / Diarrhea
Heart Murmur / Sleep problems
Headaches (Migraines, tension, cluster etc.) / Other, Please specify:
Weight Problem (over /under weight)
Irritable Bowel Syndrome
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MEDICATIONS: Please bring all your medications and supplements with you to your visit.
PRESCRIPTION MEDICATIONS - Please list on the table below ALL prescription medication you take or use.
(If you are a patient of Michigan Medicine for your primary care you may leave this blank.)
Name of Medication (Brand name) and Strength / Label Directions for Use: How were you told to take this medication? / How often do you take/use this medication? / How much do you take/use for each dose? / When did you begin taking this medication?(Date: month/year) / Why (for what medical condition) are you taking/using this medication? / When did you stop taking this medication?
(Date: month/year) / Why did you stop taking this medication?
Example:Zestril 20 mg
/ One tablet daily /Once a day
/One tablet
/March, 1998
/ High blood pressure /Still taking it
NONPRESCRIPTION MEDICATIONS AND SUPPLEMENTS (Vitamins, Minerals, Herbs, Herbal products, Remedies, and Other health products) - Please list on the table below ALL nonprescription medications and supplements you take or use. *For products with many ingredients – use page 8 of the Intake form. This is not required if you bring the supplements to your visit. Please bring supplement bottles to your appointment.
Brand name of Product and list of Ingredients(Please list each ingredient) / Amount of each Ingredient per tablet or teaspoonful / How often do you take/use this product? / How much do you take/use for each dose? / When did you begin taking this medication?
(Date: month/year) / Why
(Medical condition) are you taking or using this product? / When did you stop taking this product? (month/year) / Why did you stop taking this product?
Example:
Oscal 500 + D
Calcium Vitamin D
/500 mg
125 IU /Twice a day
/One tablet
/January 2000
/ Bone protection /I am still taking it
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Are you allergic to or have you had a “bad reaction” to any medication or other substance?
_____ Yes_____ No
If Yes, please list medication or substance and the reaction (what happened when you took it?):
Medication/Substance / ReactionSOCIAL HISTORY
What education have you completed?Current/past employment
With whom do you live?
Do you currently feel safe in your home?
Have you had or witnessed any violent/traumatic/abusive life experiences?
Have you traveled outside of the country in last year? YES/NO Where?
Do you have any pets? What kind?
What are your hobbies?
What brings you joy?
NUTRITION
What is your typical:Breakfast? Do you eat breakfast? Yes/No
Lunch?
Dinner?
Snack?
How much water do you drink/day?
How much water do you drink/day?
How much caffeine do you consume/day?
Do you use artificial sweeteners?
Are you on a special diet?
Nutrition continued:
Do you crave certain foods?
Do you avoid certain foods? Why?
Do you develop symptoms immediately after eating such as belching, bloating, and sneezing or hives?
Do you feel you have delayed symptoms (develop 24 hours or more later) after eating certain foods such as
fatigue, muscle aches, sinus congestion, etc.?
How would you describe your relationship with food?
EXERCISE/MOVEMENT
How often do you exercise/move per week?What types of exercise do you do?
What types of exercise/movement do you enjoy?
How do you feel after exercise?
Do you engage in any mindful movement (yoga, tai chi, etc.)?
SLEEP
How many hours do you sleep per night?Do you have regular sleep hours?
Do you fall asleep easily and sleep through the night?
Do you awaken refreshed?
Do you dream?
STRESS/GRIEF
Any significant life changes recently?Any major losses?
Biggest life challenges currently?
How do you manage your stress?
Does your stress level interfere with your enjoyment of life, your sleep or your relationships?
RELATIONSHIPS
Do you have someone that you can confide in?Who are the most important people in your life?
What groups/communities are you a part of?
Are any of your current relationships stressful for you?
Have you been involved in abusive relationships in your life
Did you feel safe growing up?
Was alcoholism or substance abuse present in your childhood home or in your current relationship?
ENVIRONMENT
Have you been exposed to any toxic metals at home or work?Do you feel worse at certain times of year?
RELIGION/SPIRITUALITY
How important is religion/spirituality to you?Is there a religious/spiritual tradition that you practice within and if so what?
Do you engage in prayer or meditation?
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