Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Comprehensive Intake Form - Women
Document related concepts
no text concepts found
Transcript
23198 Brook Forest Road, Abita Springs, LA 70420 985-893-4456 CONFIDENTIAL CLIENT INTAKE FORM (W) Name:______________________________ Address: ___________________________ Date of Initial Visit:_______________________ City, State, Zip _______________________________ Contact Phone:________________________email:_________________(will not be shared) Date of Birth: ___________ Age: _________ Received prior massage/bodywork? Y N Indicate types: __________________________________ Are you allergic to any products that may be used on your skin? Specify allergen and reaction: Referred by: ______________________________ REASON FOR VISIT What is your primary concern?_________________________________________________________ What are other areas of concern?______________________________________________________ When did you first notice your concerns?_________________________________________________ What was happening at or just before the time your first noticed?_____________________________ Describe what you think may have brought it on and any stressors occurring at the time: What activities provide relief? ____________________ What makes it worse? _____________________ Is this condition getting worse? ______Interfere with work? ___Sleep?_____Recreation?____ Medications/herbal remedies taken for symptoms?_____________________________________ What changes would you like to achieve in 6 months?_________________One year?_______________ MEDICAL HISTORY Blood Type: __________ Are you currently under the care of another health care provider(s)? Y N Reason: _____________ Organs surgically removed (Please note year of removal, your age at the time, organ, reason for removal, and your concerns before and after): Other surgical history (Please note year, your age, reason for surgery, your concerns before and after): Accidents or physical traumas (include falls/injuries to sacrum/head/tailbone) (Please note year, your age, & description, which body part was affected, your concerns before and after, what emotions, if any, still arise from it): Birth trauma if known: _____________________________________________________ How was your health as a child? Did you have frequent infections (kind)? Frequent medications (kind)? _________________________________________________________________________________ Vaccinations as a child and any known reactions?: __________________________________________ How is your health as an adult? Frequent infections(kind)? Frequent medications (kind)? ___________ __________________________________________________________________________________ Vaccinations as an adult and any known reactions?:__________________________________________ Have you ever been diagnosed with a major illness? ______________ If so, when, what type(s), and how it resolved: ____________________________________________________________________ Do you have allergies? If so, what kind: _________________________________________________ Do you take medications for it? If so, what kind and how often? _____________________________ Specify current medication and reason for taking and how long you have been taking: Would you like to receive information about medication side effects as they relate to your health? ____ Have you had any teeth removed? If so, which ones? ______________________________________ How is your peridontal health? ________________________________________________________ Mark any areas of current persistent pain or tension on the figures below: Occupation: ___________________________How long have you been in this occupation? ___________ What did you do prior to this if shorter than 10 years?______________________________________ Does your work satisfy you?__________________ If not, what would rather be doing?_____________ Living Situation: How many adults (sex/age/relationship) in the house? ___________________________________ How many minors? (sex/age/relatioship)____________________________________________________ How many pets? (type) ___________ Do they live inside or outside? _______________ Describe household: Is it peaceful, supportive, disharmonious, challenging, stressful, other (explain): __________________________________________________________________________________ Who is the main caregiver in your household? ____________Does anyone in your household require assisted care due to physical or mental health issues?________________________________________ Exercise (type and amount) per week: ____________________________________________________ Emotional & Spiritual Do you feel nourished by your social environment? ______Do you feel nourished by your home environment? ___________ Are you sensing a need for change? _______________ If so, in what areas? __________________________________ Are you comfortable with your weight and energy? _______ If not, what would you like it to be? __________________________________________________________________________________ What is your opinion of yourself?__________________________________________ Please describe the most negative emotion you experience____________________________________ When do you most often feel this emotion?_________________ Typically, where are you?___________ Do you experience nervousness? ______________ Anxiety? __________________Depression?_____ If so, in what situations and how often? _______________________________________________ Do you feel spiritually connected? _________________ Do you pray or have a spiritual practice?_____________________________________________ Personal History: (indicate light/moderate/heavy; daily/weekly/monthly) Do you use: Tobacco?_____ How many years? __________Alcohol (wine, liquor, beer)?_____ How many years? __________ Marijuana?____ How many years? __________Caffeine?_________ How many years? __________ Other self medications?________ How many years? __________ Have you attempted or have you quit any of these in the last 3 years? __________ On a scale of 1-10 (1 being the lesser, 10 the greater), please rate yourself in the following areas: Faith______ Hope________ Charity______ of Fun______Fear_______ Generosity_______ Sense of Humor__________ Sense Grief_________ Other (please describe)____________________ What hobbies/activities provide you with a sense of pleasure and accomplishment?_________________ What are ways in which you take care of yourself?_________________________________________ DIETARY HABITS Please check each item that is included in your usual diet: __red meat __fish __poultry __fruit __vegetables __raw foods __nuts & seeds __soy __dairy products __black tea __herbal tea __alcohol __coffee __tobacco __vitamin supplements __protein supplements __herbal supplements __sugar __yogurt or Keifer __fermented foods __sodas (diet or regular?) medicines: __birth control pills __hormone therapy __aspirin others: list Describe your eating habits (include a typical breakfast, lunch, dinner and snacks) Typical Breakfast: __________________________________________________________________ Typical Lunch: ______________________________________________________________________ Typical Dinner:______________________________________________________________________ Snacks:____________________________ How much water do you drink? Intake (glasses) _____________________________ Other beverages (please list) Do you eat lots of little meals?__________ Do you eat less frequent, more filling meals? Do you skip meals?_____ If so, which one(s)?________________ Do you eat at scheduled times? ____________ Do you cook your foods? (If not, who does?) _________________ Do you use a microwave? (How often and to cook or to heat up?) ________________________ How often do you eat out?(times per day or week) ____________________ Do you enjoy your meals? __________ How do you feel after eating? (sleepy, boated, energetic, or ?) _______________________ What is the atmosphere like at the majority of your meals (relaxed, on the go, ?)_________________________________________________________________________ Do you eat a variety of colors with each meal? _________________ What is the predominant color(s) of your meals? ________________ Do you chew your foods thoroughly? ______________ Do you have difficulty swallowing?_______________ Do you drink liquids with your meals? If so, what kind and how much? ________________________________________ Do you consume diet products (lite foods, artificial sweeteners, low fat, etc.?)____________________ What is the worse thing on your diet?________________ What foods are your weakness?_________ Are you subject to binge eating?____________If so, what foods?_____________________________ Do you experience bloating / gas / burps after eating? Y N What foods trigger this?_____________ Water Intake (glasses) _______________________ Other diet concerns:______________________________________________________ Elimination: Do you poop daily? _________________How often are your bowel movements? ____________________ Do your stools sink or float? _____ Are they soft & wet or dry & hard? _____Color of feces?________________ Do you have frequent diarrhea, constipation, alternate between diarrhea and constipation, blood in stool, mucus in stool, pain when stooling, hard and small pellet stools, smelly gas? If you are concerned about your stool, please describe why here: ______________________________ Do you experience any of the following symptoms of digestive deficiency? (circle) Dry mouth, gum and teeth problems, coated tongue, skipping breakfast, eat to calm down, indigestion or fullness after eating, difficulty swallowing, bloating, smelly burps, food sensitivities? Do you experience any of the following symptoms of digestive excess? (circle) Moist mouth, over-secretion of juices in the presence of food, pointy-tipped tongue, sore tongue, chronic nausea in the morning or when meal is delayed, irritation when taking vinegar Do you experience symptoms of ulcers: gnawing pain, burning stomach relieved by eating after eating, breath worse in morning, can only eat small amounts of food? Other: Acid foods upset Queasy with headache over eyes Bad breath Frequent vomiting (excess) Burning stomach relieved by eating (excess) Greasy Foods upset Nervous stomach Irritable bowel Loss of taste for meat Frequent sour stomach Indigestion soon after eating Foul smelling gas Burning/itching anus (parasites/food sensitivity) Respiratory disorders Itching Psoriasis Acne Fungus Boils Use of laxatives Supplements taking: Brand Amount Frequency Multi-vitamin Vitamin A Vitamin B Vitamin C Calcium Magnesium Vitamin E Enzymes Q10 Herbs Herbs Herbs Herbs Herbs Herbs Herbs Herbs ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Form (capsule, tincture, shot, homeopathic, tablet) ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ How long? Reason for taking ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ _______ ________ ________ Please circle if currently experiencing; mark past if you experienced in the past but no longer EARS: wax buildup; itchy, dry/flaky LIPS: cracks, dryness, cracks at corners of mouth, chaps frequently ACNE: where on body? If on face, where on face? Viscera Painful breasts Gall stones Pain between shoulder blades Floaters in eyes (liver) Pain in lower/mid back upon rising Bitter, metallic taste in mouth in mornings Skin peels on foot soles Kidney stones Tenderness under ribs (which side?) Wax build up in ears Blood Sugar Excessive appetite Wake in night and can’t get back to sleep (adrenal) Moods of depression Crave sweets Headaches upon rising; wear off during day Diabetes Afternoon headaches Lightheaded & feeling of hunger Get shaky if hungry Eat when nervous Irritable before meals Fatigue relieved by eating Cardiac/Circulation Swollen ankles worse at night Bruise easily Ringing in ears Tension/tightness under sternum Dizziness Headaches: Cluster/migraines/tension Varicose Veins : Location__________ Low Blood Pressure High Blood Pressure Muscles/Joints/Skeletal Painful joints Low back ache Upper back ache Spinal problems Arthritic Fibromyalgia Sciatica Artificial limbs Endocrine Get chilled often Cold hands/feet Flush easily Irritated by strong light Slow to wake and get started Perspire easily Sigh frequently Mental sluggishness Weight gain around hips and waist Decreased sugar tolerance Tendency to asthma/allergies Startle easily Unable to relax Salt craving Get drowsy often Chronic fatigue Food/environmental sensitivity Eyes/Nose Watery Eyelids swollen/puffy Sneezing attacks Pulse speeds after meals Nightmares (histamine reaction) Mineral/Vitamin/EFA deficiencies Dry skin/ mouth/eyes/nose Burning/itching skin and/or feet Excessive hair loss/course hair Frequent skin rashes Reduced appetite Sensitive to hot weather Constipation Tendency to hives PMS Painful Menses Depression before menses Leg nervousness at night Neuralgia-like pains Hands & feet go to sleep easily; numb Worrier Heart pounds after retiring Failing Memory Night sweats Anemia Muscle cramps worse during exercise Muscle/leg/toe cramps at night Joint stiffness after rising Cuts heal slowly Nails weak/ridged Hair loss Eyelids/face twitch Highly emotional Nervousness Insomnia Can’t work under pressure Irritable and restless Heart palpitations Pulse below 65 FEMALE REPRODUCTIVE HEALTH HISTORY Write a brief description of your reproductive health: Age of Menarche(first menses)_____________What was this like for you? _____________________ Are you still menstruating? _________________What is this like for you? _____________________ Date of last menstrual cycle:__________ Do you chart your cycles?_________________________ Are your cycles short (less than 28 days) or long (more than 28 days)?___________________ How many days? _____________ Do you know what day you ovulate?____ Is/was your menses regular? How long is a typical bleed? Do or did you have menstrual challenges, such as no menses, severe cramping, etc? (if so, please explain): Is your menses painful?____ What does it feel like, i.e. feels like uterus forced down from above, cramping, other: What is the color of your menses: bright red dark red brown other: Do you have dark thick blood at the beginning or the end (circle one) of cycle? Do you experience light, heavy or excessive bleeding (>one pad/hour)? Do you feel stiffness or pain in your lower back before your menses? menses? How long does it continue? Is it relieved or aggravated by Do you get headaches/migraines/dizziness associated with menses? Describe: Do you get PMS/depression/food cravings associated with menses? Describe: Do you get bloating/water retention associated with menses? Describe: Do you have body awareness of ovulation? Describe: Do you experience varicose veins, tired or weak legs, numb legs and feet when standing, sore heels when walking? (Please circle) Do you experience constipation and/or diarrhea associated with menses? Please circle and mark past or present as appropriate: Failure to ovulate Varicose veins Numb legs and feet when standing Painful intercourse Painful ovulation Tired weak legs Sore heels when walking Hemorrhoids (size & location) Bladder infections/incontinence Cysts (Breast? Ovarian? Uterine?)Uterine infections Vaginal Discharge (describe: Endometriosis Uterine polyps Cancer (reproductive system?) Pelvic inflammation Vaginitis Sexually transmitted disease (date/type): Dry vagina Other: Additional comments: Method of Contraception (circle): natural family planning pills patch diaphragm injection condoms IUD abstinence other:____________ Length of time on pills, patch, injection or IUD:_______ Have you attempted to become pregnant or have you been pregnant before? Have you experienced any terminations or miscarriages? What was your age(s) at the time, and do you feel like you have fully explored these events? If you are pregnant now, how many weeks? ____________ Due date_____________ Any challenges with this pregnancy?__________________________________________________________________ What was (is) your experience of: Pregnancy?______________________________________________________ Labor?_______________________________Delivery:_______________________________________ Post Partum?_________________________________ Did you nurse? Y N How long?____________ Describe your emotional and physical health during this pregnancy and any prior pregnancies: Any complications with birth or nursing? If you were unable to get pregnant, was there a reason you are aware of? _______________________ Have you been under treatment for infertility? Y N Describe current treatment to date (IUI, IVF, etc): Last pap smear: ___________ Results: ___________________ Do you have or have you had any sexually transmitted diseases? (What type and how were they treated?) _________________________________________________________________________ Any known medications your mother took or complications when she was pregnant with you?__________ Maternal Family History (circle): infertility fibroids endometriosis PMS menopausal symptom(s) (type): ___________ cancer (type):_________ Are you currently menopausal? Y N Date of last menstrual period ______ Post-menopausal? Y N Age of mother at menopause? __________________ Menopause (Please indicate past or present) These symptoms may or may not have been related. Hot flashes Mood Swings Vaginal Discharge Dry Vagina Insomnia Depression Anxiety Irritability Fatigue Spotting Flooding Irregular menses Memory loss Painful intercourse Increased libido Decreased libido Disturbed sleep Clotting Other symptoms not listed: _________________________________________________________________________ When did these symptoms begin?___________ Are they getting worse?_____ Better?______ Same?_______ If they are all in the past, how long did they last? _______________________ Are you on, or have you ever been on, hormone replacement therapy? Y N If so, how long?___________ Name and dose _____________________________________________ If stopped, reason? __________________________________________________________________ Other medications/herbal remedies taken for symptoms?_____________________________________ Concerns/experience _______________________ Rate your interest in sex: High Moderate Low None Do you experience pain upon intercourse? Y N Do you have or ever had difficulty experiencing orgasms? Y N Known Reason?____________________ Have you experienced a history of rape, trauma, incest, emotional or sexual abuse? were you at the time? Did you undergo counseling for this at the time? Later? Did you find it helpful? abuse? How old How are you currently experiencing the emotions surrounding the I realize these are very personal questions, but the reason I ask them is because our organs store emotional memories, and when massaging the abdomen, these emotions can surface. It is good to be prepared to acknowledge these emotions so they can be released. Additional comments: Family History Still Living? Age/Cause of Death Major Health Issues Mother Father # of Siblings Your Birth Order? Youngest, Middle, Eldest Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Family History of Abuse: Y N circle if applicable: Family History of Substance Abuse: Y N physical Suicide: Y N emotional sexual spiritual Other trauma:___________________ Please read and sign I understand that payment is due at the time of treatment unless arrangements have been made otherwise. I agree to give at least 24 hours notice of cancellation of appointment. Cases of extreme emergency are considered exceptions to this cancellation policy. I understand the therapist/practitioner does not diagnose medical illness, disease or any other physical or mental conditions. I understand the treatment here is not a replacement for medical care, nor is it a substitute for medical treatments and/or diagnosis and it is recommended that I see a qualified professional for physical or mental conditions that I may have. I understand the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does she perform any spinal manipulations. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health. Client Signature_________________________________________________Date______________________ Please read and sign Client Confidentiality Release Form I give my permission for DONNA CAIRE, my massage therapist, to take notes about me, including health history, medical and/or personal information I choose to disclose to her. I understand that this information is confidential, but I understand also that it may be used anonymously when consulting with other ATMAT practitioners for advice. Signature: ______________________________________________Date_____________
