Patient Application Form - Dr. Paul Corona

To make an appointment, simply call us at (949) 481-0118 during normal working hours, Monday – Friday. Or email me directly at DrCorona@DrpaulCoronaMD.com

If you are a new client with us, we ask that you complete this New Patient Evaluation Form and submit it here online or bring it with you to the appointment. It saves us so much time when this is completed in advance! Thank you and I look forward to working with you.

New Patient Evaluation Form

Welcome to my office. I look forward to meeting you and working with you. The more you can complete of this New Patient Form BEFORE our first meeting, the faster we can begin reaching solutions for you. Please just take a few minutes of your time.

While we would appreciate your completion of this entire form, we understand that you might not be entirely comfortable with completing some parts. That’s ok, too – just complete what you’re comfortable sharing with me, and we’ll cover the rest in our meeting together.

Thank you and I look forward to working with you. Please bring any current prescriptions with you to our meeting. Please also bring any medical records and lab work you have on hand, even if you think it doesn’t apply to the solutions you are seeking with me.

You can complete this form online, or you can Download a PDF, print it and complete it. Please either scan it and return it to me at DrCorona@DrPaulCoronaMD.com or bring it with you to the appointment.

Name
First Last
Phone
Email
Who referred you (if anyone) and what is the primary reason for you being here today?*
What do you do for work (if you work), or where are you in school?*
What are your hobbies? What do you do to relieve stress or just have fun?*
Physical Details
List symptoms you suffer from such as headaches neck/shoulder/back pain, Fibromyalgia, Irritable Bowel Syndrome, acid reflux, ulcers, high blood pressure, chest pain/tightness, difficulty breathing, skin problems or any other physical, sometimes chronic symptoms.*
How is your sleep quality? If you have insomnia, how severe is it and for how long?*
How is your daytime energy, motivation and drive?*
Are you happy with your weight and level of physical fitness? If you work out, please give details.*
Do you smoke? If so how much and for how long?*
Do you drink? If so, how much and how often, on average? Do people who know you think it’s a problem?*
Emotional Details
Describe any significant emotional symptoms, i.e., worry, rumination, obsessive thinking and behaviors, nervous habits, frequent sadness or crying, hopelessness, anger outbursts, apathy, difficulty with focus, mood swings*
Tell me about any significant family history, especially regarding mood disorders, psychiatric hospitalizations, alcoholism or other addictions, or dysfunctional lives in general.*
Medical History
Do you have a history of any medical problems? Give significant details, and bring any lab work and results of diagnostic studies that have been done, as well as consultation notes from any doctors or other health providers.*
Have you seen psychologists and other counselors, primary care doctors, psychiatrists, alternative health-care providers or anyone else you are treated by regarding your emotional and physical health? If so give details.*
List all significant medications you have taken, whether by prescription, by mail-order/distributor or over-the-counter medications, vitamins, supplements, etc. Give as many details as possible regarding their dosages and how long they were taken.*
What were the specific benefits and/or side effects?*
Do you have any significant allergic history to medications, antibiotics, foods or other environmental allergens such as pollen, dust, pets, grasses?*
Are you:*
- Male
- Female
Important!
On a scale of 1 to 100, with 0 being the worst you can imagine feeling and 100 being the best you can imagine feeling, where are you now?*
Please enter a number from 1 to 100.
When were the worst and best times of your life?*
When did you feel yourself and when and how did that change?*
What are the key goals you would like to achieve by my treatment with me?*

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Online Resources

Healing the Mind and Body: Volume 1

Over the last 30 years, Dr. Paul Corona has treated tens of thousands of patients who struggle with a number of common ailments and issues because of chemical imbalances in the nervous system.

Purchase

Healing the Mind and Body: Volume 2

In this Doctor and Patient Guide of Healing the Mind and Body you will learn: Why the cooperative healing process begins in the exam room and what you can do during the interview to maximize its benefits.

Purchase

Healing the Mind and Body: Volume 3

Patients are as likely to be interested as doctors in this third volume of Dr. Paul Corona’s Healing the Mind and Body by discovering the critical importance of…

Purchase

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New Patient Evaluation Form

Physical Details

Emotional Details

Medical History

Important!

Online Resources

Healing the Mind and Body: Volume 1

Healing the Mind and Body: Volume 2

Healing the Mind and Body: Volume 3