New Patient Information

All appointments are non refundable unless canceled w 72 hours notice

Privacy Practices Acknowledgment

Prior to completing this evaluation form, please review our Notice Of Privacy Practices. It is important that you understand your rights as a patient and acknowledge that you have reviewed the notice before we can begin treatment.

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. I authorize BOMAMED to contact me regarding treatment, appointments, payment or other health related information in the following manner:

If you selected via Phone as a contact option, is there an authorized person(s) ONLY with whom we should leave voice message?
On occasion we may send out non-health related mailings (e.g. – newsletter). Would you like to be included in such mailings?
Please type your initials this box to confirm acknowlegement of the Privacy Notice.
Personal Information
Phone
Provide at least one.
Address
Emergency Contact
Insurance Policy
Family Physician
Personal Medical & Family Health History

Please indicate those that are current health for your self and your family members with a "C" under appropriate person's column. "P" should be used to indicate a past problem. Leave blank those that do not apply to you.

 YouFatherMotherSpouseBrotherSisterChildren
Age
Allergies
Diabetes
High Blood Pressure
Seizures
Thyroid Disease
Cancer
Hepatitis
Heart Disease
HIV/Aids
Diet

How often you eat the following:

 DailyWeeklyMonthly
Red Meat
Poultry
Cooked Fish
Raw Fish
Tofu
Fried Foods
Steamed Foods
Cooked Foods
Raw Foods
Bread
Potatoes
Pasta
Rice/Grains
Vegetables
Vegetable Juices
Fruit Juices
Sweets
Junk Foods
Soda
Sugar
Alcohol
Fruit
Coffee
Tea
Current Medications

Please include vitamins, herbs, supplements, and prescriptions medications

Recreational Drugs

Please include cigarettes and other tobacco products.

Please select your symptoms from the following list:

LU
SP
HT
KD
SI
LI
ST
UB
LV
Body Temperature
Perspiration
Sleep
Thirst
Energy
GB
Mind
Others
Women
Men
Physical assessment of pain
IC Symptoms
****** THE REMAINDER OF THIS FORM IS FOR INTERSTITIAL CYSTITIS PATIENTS ONLY. IF YOU ARE AN INTERSTITIAL CYSTITIS PATIENT, PLEASE COMPLETE THIS SECTION. IF YOU ARE NOT AN INTERSTITIAL CYSTITIS PATIENT, THEN YOU ARE FINISHED WITH THE FORM. SKIP TO THE END AND CLICK SUBMIT. ******
Please list your history of taking:
Please list any history of the following
Do you consume any of the following foods and with what regularity?