Preliminary Application Form

At the Villa Natura Medical Institute, our focus is on your well being. Please submit this electronic form so we may pre analyze your case. If you wish to speak to us directly please call 407.549.5459. If you prefer to print out his form and mail or fax it to us, please click here.

Patient Information
First Name:
 
Last Name:
Address:
  
Home Phone:
City:
  
Work Phone:
State:
  
Cell Phone:
Zip Code:
 
E-mail:
Date of Birth:
 
Age:


Emergency Contact
First Name:
  
Last Name:
Address:
  
Home Phone:
City:
  
Work Phone:
State:
  
Cell Phone:
Zip Code:
  
E-mail:
Relationship:
  
Age:

First Name:
  
Last Name:
Address:
  
Home Phone:
City:
  
Work Phone:
State:
  
Cell Phone:
Zip Code:
  
E-mail:
Relationship:
  
Age:


Health Information
Allergies
Allergy 1:
  
Reaction:
Allergy 2:
  
Reaction:
Allergy 3:
  
Reaction:
Allergy 4:
  
Reaction:


Present Condition
Karnofsky Rating Scale:
  
Score:

100 Normal; no complaints; no evidence of disease
90 Able to carry on normal activity; minor symptoms of disease
80 Normal Activity with effort
70 Cares for self; unable to carry on normal activity or active work
60 Requires occasional assistance but is able to care for needs
50 Requires considerable assistance and frequent medical care
40 Disabled; requires special care and assistance
30 Severely disabled; hospitalization is indicated, death not imminent
20 Very sick; hospitalization necessary; active treatment is necessary
10 Moribund, fatal processes progressing rapidly
0 Dead
Appetite:
  
Anema:
Urinary:
  
Jaundiced:
Pain:
  
Bleeding:
Fluid:
  
Bowel Movmt.:
Fatigue:
  
Attitude:
Sexual Activity:
  
Broken Bones:
Blood Pressure:
      


Original Cancer Diagnosis
Original Cancer Type:
  
Date Diagnosed (Original):
Original Cancer Location:
  
Hospital / Clinic
/ Office:
Recurrence Location:
  
Date Diagnosed (Metastases):
Details:


Surgery
Surgery:
 yes no  
Date:
Location:
  
Hospital / Clinic:
Surgeon:
  
Results:
Complications:


Chemotherapy
Chemotherapy:
 yes no  
Date Initiated:
Type:
  
Date Completed :
Oncologist:
  
Hospital / Clinic:
# of Visits:
  
Results:
Complications:


Radiation
Radiation:
 yes no  
Date Initiated:
RADS:
  
Date Completed :
Radiologist:
  
Hospital / Clinic:
# of Visits:
  
Results:
Complications:


Other Therapies
  PAST:     CURRENT:
Therapy:
  
Therapy:
Drugs:
  
Drugs:
Medications:
  
Medications:
Herbs:
  
Herbs:
Vitamins:
  
Vitamins:
Diet:
  
Diet:
Physician:
  
Physician:
Results:
  
Results:
Complications:


Test Results
Name of Test :
      
Reason for Test :
      
Results:

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