Become a Patient – Infinity Health Care

Infinity Health Care provides high quality, comprehensive wellness programs that are unique for the area. In order to do the best possible job, we must have the most accurate information to begin with. Please take the time and care to fill out this entire form. If fields are left unanswered, your form will not be processed. This wide-ranging, confidential questionnaire is used to create a partial analysis of your case before you are even seen in the office. As we must do work on your case in advance, please meet us halfway and spend the time to do your part. We believe it will be worth your effort.

PATIENT INFORMATION

Name
Address
City
State
Zip
Email Address

Sex:
M F

Age
Birth date
Height
Weight

Marital status:

Single Married Widowed Separated Divorced

Occupation
Employer

Tell us how you heard about us. If you were referred by someone, please enter their first and last name so we may thank them.

Have you had a COVID vaccine? Yes No

Are you seeking treatment for COVID vaccine damage? Yes No

PHONE NUMBERS

Home
Mobile
Work
Ext

Best time and place to reach you:

IN CASE OF EMERGENCY, CONTACT:

Name
Relationship
Home Phone
Work Phone

ACCIDENT INFORMATION
Is condition due to an accident?
Yes No

Type of accident:
Auto Work Home Other

Short description of accident:

To whom have you made a report of your accident?
Auto Insurance Employer Worker’s Comp. Other

Attorney Name (if applicable)

FAMILY HISTORY

Mark yes for any illnesses which have occurred in any of your family blood relatives:

Illness Family History	Yes	No
Diabetes	Yes	No
Cancer	Yes	No
Bleeding Tendency	Yes	No
Kidney Disease	Yes	No
Tuberculosis	Yes	No
Heart Disease	Yes	No
Stroke	Yes	No
High Blood Pressure	Yes	No
Nervous Illness	Yes	No
Allergy	Yes	No

Why are you here and what would you like to accomplish with our help?

YOUR HEALTH HISTORY

SYMPTOMS
Select symptoms you currently have or have had in the past year.

You must check either Yes or No.

GENERAL

Symptom	Yes	No
1. Anxiety	Yes	No
2. Catch colds easily	Yes	No
3. Chills	Yes	No
4. Confusion	Yes	No
5. Depression	Yes	No
6. Difficult concentration	Yes	No
7. Dizziness	Yes	No
8. Fainting	Yes	No
9. Fatigue	Yes	No
10. Fever	Yes	No
11. Forgetfulness	Yes	No
12. Headache	Yes	No
13. Indecision	Yes	No
14. Irritability	Yes	No
15. Migraine	Yes	No
16. Nervousness	Yes	No
17. Numbness	Yes	No
18. Sensitive to weather changes	Yes	No
19. Trouble falling asleep	Yes	No
20. Fall asleep but awaken later	Yes	No
21. Sweats	Yes	No
22. Weight gain	Yes	No
23. Weight loss	Yes	No

Is there one emotion you experience more often than others?
Anger Joy Worry Sadness Fear

Which weather do you find less tolerable?
Hot Cold Neither Both

Any thoughts, ideas, fears that you have often?

Any recurring dreams?

Any recurring nightmares?

EYE, EAR, NOSE, THROAT

Symptom	Yes	No
24. Allergies / Hay fever	Yes	No
25. Bleeding gums	Yes	No
26. Blurred vision	Yes	No
27. Dry eyes	Yes	No
28. Runny eyes	Yes	No
29. Double vision	Yes	No
30. Difficulty swallowing	Yes	No
31. Earache	Yes	No
32. Ear discharge	Yes	No
33. Sore throat	Yes	No
34. Hoarseness	Yes	No
35. Loss of hearing	Yes	No
36. Nasal congestion	Yes	No
37. Nosebleeds	Yes	No
38. Ringing in ears	Yes	No
39. Sinus problems	Yes	No
40. Vision—Flashes	Yes	No
41. Vision—Halos	Yes	No

RESPIRATORY

Symptom	Yes	No
42. Asthma	Yes	No
43. Cough	Yes	No
44. Shortness of breath	Yes	No
45. Wheezing	Yes	No

GENITOURINARY

Symptom	Yes	No
46. Blood in urine	Yes	No
47. Frequent urination	Yes	No
48. Lack of bladder control	Yes	No
49. Painful urination	Yes	No

How often do you urinate daily?

GASTROINTESITNAL

Symptom	Yes	No
50. Appetite poor	Yes	No
51. Belching	Yes	No
52. Bloating	Yes	No
53. Bowel changes	Yes	No
54. Canker sores inside mouth	Yes	No
55. Constipation	Yes	No
56. Diarrhea	Yes	No
57. Excessive hunger	Yes	No
58. Excessive thirst	Yes	No
59. Gas (flatulence)	Yes	No
60. Hard stools	Yes	No
61. Hemorrhoids	Yes	No
62. Indigestion	Yes	No
63. Nausea	Yes	No
64. Reflux	Yes	No
65. Rectal bleeding	Yes	No
66. Soft stools	Yes	No
67. Stomach pain	Yes	No
68. Vomiting	Yes	No
69. Vomiting blood	Yes	No

How often do you have a bowel movement?

What foods / flavors do you strongly dislike?

What foods / flavors do you crave?

CARDIOVASCULAR

Symptom	Yes	No
70. Chest pain	Yes	No
71. High blood pressure	Yes	No
72. Irregular heart beat	Yes	No
73. Low blood pressure	Yes	No
74. Poor circulation	Yes	No
75. Rapid heart beat	Yes	No
76. Swelling of ankles	Yes	No
77. Varicose veins	Yes	No

MUSCLE/JOINT/BONE

Pain, weakness, numbness in:	Yes	No
78. Arm	Yes	No
79. Back	Yes	No
80. Feet or ankles	Yes	No
81. Hands	Yes	No
82. Hips	Yes	No
83. Knees	Yes	No
84. Legs	Yes	No
85. Neck	Yes	No

Symptom	Yes	No
86. Fracture easily	Yes	No
87. Strained muscles	Yes	No
88. Sprained ligaments	Yes	No

SKIN

Symptom	Yes	No
89. Acne	Yes	No
90. Bruise easily	Yes	No
91. Cold sores on lips	Yes	No
92. Dry skin	Yes	No
93. Eczema	Yes	No
94. Flaky scalp	Yes	No
95. Heavy perspiration	Yes	No
96. Hives	Yes	No
97. Itching	Yes	No
98. Oily skin	Yes	No
99. Psoriasis	Yes	No
100. Rash	Yes	No
101. Rosacea	Yes	No
102. Scanty perspiration	Yes	No
103. Scars	Yes	No
104. Sore that won’t heal	Yes	No
105. Warts	Yes	No

Are your fingernails:	Yes	No
106. Soft	Yes	No
107. Splitting	Yes	No
108. Ridged, brittle	Yes	No
109. Discolored	Yes	No

MEN ONLY

Symptom	Yes	No
110. Breast lump	Yes	No
111. Erection difficulties	Yes	No
112. Lump in testicles	Yes	No
113. Penis discharge	Yes	No
114. Sexual difficulties	Yes	No
115. Sore on penis	Yes	No

Other:

WOMEN ONLY

Symptom	Yes	No
116. Abnormal Pap Smear	Yes	No
117. Bleeding between periods	Yes	No
118. Irregular periods	Yes	No
119. Breast lump	Yes	No
120. Nipple discharge	Yes	No
121. Fibrocystic breasts	Yes	No
122. Extreme menstrual pain	Yes	No
123. Premenstrual syndrome	Yes	No
124. Hot flashes	Yes	No
125. Fibroid tumors	Yes	No
126. Ovarian cysts	Yes	No
127. Ovarian pain	Yes	No
128. Painful intercourse	Yes	No
129. Sexual difficulties	Yes	No
130. Vaginal discharge	Yes	No
131. Yeast infections	Yes	No

Other:

Date of last menstrual period

Number of pregnancies

Number of children

Are you pregnant?
Yes No

Date of last Pap Smear:

Have you had a mammogram?
Yes No
Date:

CONDITIONS

Symptom	Yes	No
132. AIDS	Yes	No
133. Alcoholism	Yes	No
134. Anemia	Yes	No
135. Anorexia	Yes	No
136. Appendicitis	Yes	No
137. Arthritis	Yes	No
138. Asthma	Yes	No
139. Bleeding Disorders	Yes	No
140. Bronchitis	Yes	No
141. Bulimia	Yes	No
142. Cancer	Yes	No
143. Cataracts	Yes	No
144. Chemical Dependency	Yes	No
145. Chicken Pox	Yes	No
146. Diabetes	Yes	No
147. Emphysema	Yes	No
148. Epilepsy	Yes	No
149. Glaucoma	Yes	No
150. Goiter	Yes	No
151. Gonorrhea	Yes	No
152. Gout	Yes	No
153. Heart Disease	Yes	No
154. Hepatitis	Yes	No
155. Hernia	Yes	No
156. Herpes	Yes	No
157. High Cholesterol	Yes	No
158. HIV Positive	Yes	No
159. Jaundice	Yes	No
160. Kidney Disease	Yes	No
161. Liver Disease	Yes	No
162. Measles	Yes	No
163. Migraine Headaches	Yes	No
164. Miscarriage	Yes	No
165. Mononucleosis	Yes	No
166. Multiple Sclerosis	Yes	No
167. Mumps	Yes	No
168. Nervous Disorder	Yes	No
169. Osteoporosis	Yes	No
170. Pacemaker	Yes	No
171. Pneumonia	Yes	No
172. Polio	Yes	No
173. Prostate Problem	Yes	No
174. Psychiatric Care	Yes	No
175. Rheumatic Fever	Yes	No
176. Scarlet Fever	Yes	No
177. Stroke	Yes	No
178. Suicide Attempt	Yes	No
179. Syphilis	Yes	No
180. Thyroid Problems	Yes	No
181. Tonsillitis	Yes	No
182. Tuberculosis	Yes	No
183. Typhoid Fever	Yes	No
184. Ulcers	Yes	No
185. Vaginal Infections	Yes	No
186. Vein Trouble	Yes	No

None Moderate Daily Heavy

WORK ACTIVITY

Sitting Standing Light Labor Heavy Labor

HABITS

Use checkboxes to indicate if you have the specified habit, otherwise leave blank.

Habit	Checkbox		Usage
High Stress Level		Reason:
Smoking		Packs per Day:
Alcohol		Drinks per Week:
Coffee/Caffeine Drinks		Amount/Day:
Soda Pop		Amount/Day:
DIET soda		Amount/Day:
Marijuana*		Amount/Week:

*This substance can interfere with some of my treatments, so I appreciate your being honest about this.

INJURIES/SURGERIES

Injuries/Surgeries you have had	Description	Year
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries
Other Injuries

ALLERGIES

Have you ever had any allergic reactions to shellfish?	Yes	No
Are you allergic to Novocain or Xylocaine?	Yes	No
Do you have allergic reactions to latex?	Yes	No

Please list below separated by commas any allergies known to you. (foods, molds, etc.)

PRESCRIPTION MEDICATIONS

Please list below separated by commas your current medications.

Pharmacy Name:
Pharmacy Phone:

VITAMINS / HERBS / MINERALS

Please list below separated by commas any supplements you currently take.

MAJOR HEALTH CONCERNS

If you have only one major health concern, please only fill out the “Problem #1” section.

Problem #1
Describe your problem and associated symptoms:

What makes it worse (certain weather, activity, rest, certain foods, etc.)?

What makes it feel better?

When does it bother you most (time of day, season, before periods, etc.)?

If your problem causes you pain, describe it as closely as possible:

Check all that apply:
sore, bruised aching cramping, drawing sharp, stabbing burning

Choose one:
Steady Throbbing Intermittent

Please mark on the 1-10 scale your overall level of pain at present

Problem #2
Describe your problem and associated symptoms:

What makes it worse (certain weather, activity, rest, certain foods, etc.)?

What makes it feel better?

When does it bother you most (time of day, season, before periods, etc.)?

If your problem causes you pain, describe it as closely as possible:

Check all that apply:
sore, bruised aching cramping, drawing sharp, stabbing burning

Choose one:
Steady Throbbing Intermittent

Please mark on the 1-10 scale your overall level of pain at present.

Problem #3
Describe your problem and associated symptoms:

What makes it worse (certain weather, activity, rest, certain foods, etc.)?

What makes it feel better?

When does it bother you most (time of day, season, before periods, etc.)?

If your problem causes you pain, describe it as closely as possible:

Check all that apply:
sore, bruised aching cramping, drawing sharp, stabbing burning

Choose one:
Steady Throbbing Intermittent

Please mark on the 1-10 scale your overall level of pain at present.

Finalize and Submit
Once your intake form has been reviewed, a decision will be made as to whether Dr. Negri can take your case, or possibly need to refer you to another doctor. You will receive an email giving you instructions on how to proceed from there.