Download Patient Intake Form - Zygmont Chiropractic Center

Sarah Johnson L. Ac.
Austin, TX 78704
Patient Intake Form
Please take time to completely fill out this form. It will help me in providing you with a careful
evaluation of your health. If you have any questions, please feel free to ask. All information is
confidential.
Personal Information:
Name:_______________________________ D.O.B.__________ Age:________ Today’s Date:________
Address:_________________________________________ City:________________________________
State:______ Zip:__________ Primary Phone:___________________ Alt. Phone:___________________
Email:____________________________________ Occupation:_________________________________
Emergency Contact Person:_____________________________ Number:__________________________
Primary Care Provider:_________________________________ Number:_________________________
How did you hear about us?
________________________________
Marital Status:  Single  Married  Separated  Divorced  Widowed  Partnered
Partner’s Name:________________________ Partner’s Age:_______ Occupation:__________________
Have you ever been treated by Oriental medicine before?  Yes  No
Medical Information:
Main Complaint (including diagnosis, duration, other forms of treatment):
Additional Complaints/Concerns (list in order of significance):
Significant Traumas/Surgeries:
Medications, Herbs, Supplements:
Allergies (environmental, food, chemical, or drug):
Diet & Exercise:
Meals per day:____ Caffeinated Beverages (per day or week):____ Alcohol (per day or week):_____
Are you on any type of special or restricted diet?
Do you smoke?  Yes  No If so, how many cigarettes (per day or week)?
Do you use any recreational drugs?  Yes  No If so, what type and how often?___________________
Do you exercise regularly?  Yes  No
No. of days per week:_____ Length of workout:_____ Type of Activity:___________________________
Family Medical History
Please check any condition that applies to your immediate family. Write
“F” for father, “M” for mother, “S” for sister, “B” for brother, “GM” for
grandmother, and “GF” for grandfather next to the box you checked.
 Diabetes ________
 Heart Disease ________
 Allergies ________
 Cancer ________
 Stroke ________
 Asthma ________
 High Blood Pressure ________
 Seizures ________
 Other _______________________________________
Personal Medical History Please check any current or previous conditions
.
 Diabetes
 Heart Disease
 Asthma
 Injury/Trauma
 Kidney Disease
 Meningitis
 Epilepsy
 Nerve Damage
 Chronic Pain
 Ulcers
 Paralysis
 Lung Disease
 STD/STI
 Liver Disease
 High Cholesterol
 Glaucoma
 Chemical Dependency
 Auto Immune Disease
 Hypo/Hyperglycemia
 Anemia
 Tuberculosis
 Shingles
 Hepatitis
 Migraines
 Skin Disorder
 Rheumatic Fever
 Thyroid Disorder
 Vein Disorders
 Infertility
 Emphysema
 COPD
 Beeding/Hemorrhage
 Nervous Disorder
 Mental Illness
 Hypertension
 Acid Reflux Disease
 Crohn’s Disease
 Seizures
Please check any of the symptoms you have experienced in the last 3 months:
Body Temperature (Kidney Organ System)
 Cold Hands
 Cold Feet
 Sweaty Palms
 Sweaty Feet
 Hot Body Temperature
 Cold Body Temperature
 Afternoon Flushing
 Night Time Urination
 Profuse Perspiration
 Lack of Perspiration
 Night Sweating
 Perspire Easily
 Strong Thirst
 Hot Flashes
Energy and Stamina (Lung and Kidney System)
 Easily Fatigued
 Lethargy
 Shortness of Breath  Sweating
 Prone to Illness
 Frequent Colds
 Wheezing
 Allergies
Blood Function (Liver, Heart, Spleen System)
 Dizziness
 Poor Night Vision
 Floaters
 Tingling in Extremities
 Poor Memory
 Difficulty Concentrating
 Itchy or Dryness
 Blurred Vision
 Tinnitus
 Fainting
 Weak or Brittle Nails
Heart Function
 Heart Palpitations
 Anxiety
 Mental Restlessness
 Chest Pain
 Hemophilia
 Manic Moods
 Restless Dreams
 Insomnia
 Arrhythmia
 Rapid Heart Beat
 Forgetfulness
 Hallucinations
 Depression
 High Blood Pressure
 Mitral Valve Prolapse
 Tongue Ulcers
 Speech Impediment
 Severe Shyness
 Low Blood Pressure
 Heart Murmur
Lung Function
 Persistent Cough
 Nosebleeds
 Sinus Congestion
 Wheezing
 Phlegm Production
 Sneezing
 Chronic Allergies
 Difficulty Breathing  Dry or Flaky Skin
 Nasal Dryness
 Sore Throat
 Cystic Fibrosis
Spleen Function
 Low/Weak Appetite  Abdominal Bloating  Strong Food Cravings
 Abrupt Weight Gain  Gas
 Gurgling in Intestines
 Abrupt Weight Loss  Bruise Easily
 Fatigue After a Meal
 Hemorrhoids
 Hypoglycemia
 Indigestion
Stomach Function
 Stomach Ache
 Acid Reflux
 Ravenous Appetite
 Bad Breath
 Bleeding Gums
 Heartburn
 Stomach Ulcer
 Belching
 Hiccups
 Nausea
 Vomiting
 Mouth Ulcers
Bowel Function and Elimination (Intestinal Function)
 Loose Stools
 Diarrhea
 Incomplete Stools
 Constipation
 Blood in Stools
 Mucous in Stools
 IBS or Colitis
 Small, Hard, Dry Stools
 Less than 1 BM/Day
 Chron’s Disease
 Eating Disorder
Accumulated Dampness
 Mental Fogginess
 Swollen Hands
 Poor Mental Focus
 Mental Sluggishness  Swollen Feet
 Joint Stiffness/Ache
 Chest Congestion
 Heaviness of head, limbs, or whole body
 Edema in Legs
 Edema in Abdomen
Liver and Gallbladder Function
 Chest Pain
 Chest Tightness
 Body Tension
 Muscle Spasms
 Muscle Cramps
 Seizures
 Teeth Clenching
 Irritability
 Easy to Anger
 Easily Frustrated
 Convulsions
 Numbness/Tingling
 Chronic Neck Tension
 Difficulties with Stress
 Depression
 Skin Rashes
 Pain in Ribcage
 Acne
 Heaviness in Ribcage  Headaches
 Lump in Throat
 Migraines
 Shoulder Tension
 Gall Stones
 Ringing in Ears
 Eye Pain/Dryness
 Alternating Diarrhea and Constipation
Eyes (Liver Function)
 Itchy Eyes
 Dry Eyes
 Watery Eyes
 Grittiness
 Poor Night Vision
 Red and Irritated
 Bloodshot
 Seeing Spots
 Near Sighted
 Far Sighted
 Astigmatism
 Glaucoma
 Cold Lower Back
 Cold Hips/Buttocks
 Cold Knees
 Incontinence
 Hair Loss
 Early Graying
 Hearing Loss
 Quick to Fright
Kidney and Bladder Function
 Frequent Cavities
 Broken/Loose Teeth
 Weak Bones
 Ringing in Ears
 Weak Knees
 Knee Soreness
 Low Back Pain
 Prostate Problems
Urinary Function
 Normal Color
 Reddish Color
 Dark Yellow
 Cloudy
 Clear Color
 Strong Odor
 Difficulty Initiating the Stream of Urine
 Small Amount
 Large Amount
 Frequent Urination
 Night Time Urination
 Dribbling
 UTI/Pain/Burning
 Weak Stream
 Burning Sensation
Female Reproductive Function
Age of First Period______
Length of Cycle______
Duration of Bleeding______
Day of Ovulation______
Date of Last PAP______
Date of Last Period______
Number of Pregnancies______ Vaginal Births______
Cesarean Births______
Ectopic Pregnancies______
Miscarriages______
Abortions______
Failed IUIs______
Failed IVFs______
Menstrual Cycle
My periods are:
 Like Clockwork
 Somewhat Regular
 Erratic
If your cycle is erratic: Shortest # of cycle days______ Longest # of cycle days______
 PMS:
 Irritability
 Food Cravings
 Spotting Before Period
 Headache/Migraine  Constipation
 Low Back Pain
 Bloating
 Dizziness
 Breast Soreness
 Fatigue
 Heavy Bleeding
 Scanty Bleeding
 Dark Colored Blood  Watery or Pink Blood
 Pain is Sharp
 Pain is Dull
 Pain Improves with Rest
 Normal Bleeding
 Interrupted Flow
 Clotting
 Painful Periods
 Pain Improves with Heat
 Pain Improves with Exercise
During Ovulation Cervical Mucus is clear, stretchy, and abundant.
 Yes
 No
Previous Diagnostic Assessments
 Amenorrhea
 Anovulation
 Anti-sperm Antibodies
 Autoimmune Oopharitis
 Elevated FSH Levels
 Endometriosis
 Fallopian Tube Blockage
 Habitual Miscarraige
 Hyperprolictinemia
 Anovulation
 Luteal Phase Defect
 Menorrhagia
 Ovarian Cyst
 Ovarian Hyperstimulation Syndrome
 Pelvic Inflammatory Disease (PID)
 Polycystic Ovarian Syndrome (PCOS)
 Premature Menopause
 Premature Ovarian Failure (POF)
 Resistant Ovarian Syndrome
 Unexplained Infertility
 Uterine Fibroids
 Uterine Septum
Previous Gynecological Surgeries
 Dilation and Curettage (D&C)
 Falloposcopy
 Hysterosalpingogram (HSG)
 Hysteroscopy
 Hysterectomy
 Laparoscopy (endometriosis)
 Laparoscopy (ovarian cysts)
 Laparoscopy (uterine fibroids)
 Mastectomy/Lumpectomy
 Myomectomy
 Tuboplasty
 Other:
______________________________________
Male Reproductive Function
 Testicular Swelling  Sensation of Heat in Testicles Testicular Pain
 Scrotal Itching
 Retrograde Ejaculation
 Prostititis
 Difficulty Ejaculating Difficulty Urinating
 Erectile Dysfunction
 Vasectomy
 Vasectomy Reversal
 Epididymitis
 Impotence
 Infertility
 Vericocele
 Hernia
History of Sexually Transmitted Disease (STD):
Medical Evaluation:
I have been evaluated by a medical physician for the condition being treated in the past 12 months.
 Yes
 No
Permission to Maintain Medical Privacy and Share Medical Information:
All of the information that you provide is strictly confidential. It is our policy never to disclose any
personal or medical information about any patient under our care without first obtaining your express
permission to do so.
In an effort to maximize your clinical results, we may want to contact your Doctor(s), and send them
periodic updates about your case and your progress. Do you grant your permission for us to discuss the
details of your case with your Medical Doctor?
 Yes
 No