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Patient Intake Form Full Name: Date: Date of Birth: Age: Contact Phone #: Email: Address: Street City State: Zip: In Emergency notify: Family Physician How did you hear about us? Main Problem: you would like us to help with __________________________ When did this problem begin? Precipitating factors? Have you been given a diagnosis for this? If so when? To what extent does this interfere with your daily activities (work, sleep, sex, etc.)? What kind of treatment have you tried? What makes this problem worse? What makes this problem better? Past Medical History (Please include the month/year): Significant Illness: Cancer Diabetes Seizures Arthritis Anemia Breathing Problems HIV/AIDS Positive Hepatitis Thyroid Disease Tuberculosis Hypertension Emotional Balance Heart Disease Digestive Disorders Veneral Disease Other: Surgeries: Significant Trauma: List any allergies you have: Family Medical History: Cancer Diabetes Hepatitis Hypertension Asthma Alcoholism Other Stroke List any medications you may be taking: Occupation: Do you usually work o Indoors o Outdoors Personal: Height______ Weight_______ One year ago________ Weight maximum___________@year___________ Do you smoke? o Yes o No Do you exercise regularly? o Yes o No Diet: How much coffee do you drink? ____cups/day Colas________number/day. Teas_________cups/day. What kind of alcoholic beverages do you usually drink?_____ How much water do you drink per day?____ Are you vegetarian? o Yes o No Please check if you have or have had (in the last three months) any of the following diseases or conditions? General: [] Poor appetite [] Poor sleeping [] Fatigue [] Fevers [] Chills [] Night sweats [] Sweat easily [] Tremors [] Cravings [] Change in appetite [] Poor balance [] Bleed or bruise easily [] Localized weakness weight loss weight gain [] Peculiar tastes [] Desire hot food [] Strong thirst (cold or hot [] Desire cold food [] Sudden energy drops (What time of a day)___ drinks) Favorite time of year___________ Worst time of year__________ Skin & hair: [] Rashes [] Ulcerations [] Hives [] Eczema [] Pimples [] Dandruff [] Dry skin [] Recent moles [] Loss of hair [] Purpura [] Change in hair or skin textures [] Itching [] Other? Musculoskeletal: [] Joint disorders [] Weakness muscles [] Pain /soreness in the muscles [] Swelling of hands/feet [] Difficult walking [] Cold hands/feet [] Spinal curvature [] Back pain [] Hernia [] Numbness [] Tingling [] Paralysis [] Neck pain [] Neck tightness [] Shoulder pain [] Hand/wrist pain [] Hip pain [] Knee pain [] Sprain of joint [] Other Head, eyes, ears, nose and throat: [] Dizziness [] Concussions [] Migraines [] Glasses/lens [] Eye strain [] Eye pain [] Color blindness [] Night blindness [] Poor vision [] Cataracts [] Blurry vision [] Earaches [] Ringing in ears [] Poor hearing [] Spots in front of eyes [] Sinus problems [] Nose bleeding [] Sore throat [] Grinding teeth [] Teeth problems [] Facial pain [] Jaw clicks [] Sores on lips/tongue [] Difficult swallowing [] Other Cardiovascular: [] High blood pressure [] Low blood pressure [] Palpitation [] Fainting [] Irregular heartbeat [] Rapid heartbeat [] Other [] Chest pain [] Phlebitis [] Varicose veins Respiratory: [] Cough [] Coughing blood [] Difficulty in breathing [] Chest pain [] Wheezing [] Bronchitis [] Pneumonia [] Phlegm production---What color?__________ Gastrointestinal: [] Nausea [] Vomiting [] Constipation [] Gas [] Blood in stools [] Indigestion [] Bad breath [] Rectal pain [] Hemorrhoids [] Abdominal pain/cramps [] Gallbladder problems [] Diarrhea [] Belching [] Black stools [] Parasites [] Chronic laxative use Bowel movements: Frequency___ Color_______ Odor_______ Texture/Form_________ Neuro-psychological: [] Loss of balance [] Depression [] Lack of coordination [] Anxiety [] Stress [] Concussion [] Bad temper [] Bi-polar Genito-urinary: [] Pain on urination [] Frequent urination [] Urgent to urinate [] Unable to hold urine [] Kidney stones [] Dribbling [] Frequent urinary tract infection [] Itching of genital [] Blood in urine [] Pause of flow [] Pain in genital [] Other Female: [] Frequent vaginal infections [] Pelvic infection [] Endometriosis [] Vaginal/genital discharge [] Fibroids [] Ovarian cysts [] Irregular periods [] Clots [] Pain/cramps prior/during periods _____number of pregnancies _____number of births _____miscarriages _____abortions _____premature births _____cesareans _____difficult delivery First date of last period__________________ Age of first menses____ Duration of periods______days, cycle____days Do you practice birth control? [] yes [] no If yes, what type and for how long?_____________________________ If you’re on birth control pills, what are you taking and for how long?____________________________________________________________ Male: [] Prostate problems [] Discharge [] Frequent seminal emission [] Ejaculation problems [] Impotence [] Fertility problems [] Painful/swollen testicles [] Other I understand the above information and guarantee this form was completed correctly to the best of my knowledge. Signature: Date:
