Download Intake Form

INTAKE FORM
NAME:____________________________________________________
DATE: ___________
Reason for your Visit: _______________________________________Medication Allergies___________________________________
Has your child had any major illnesses since your last office visit?
□ No □ Yes _______________________
Has your child had any surgeries since your last office visit?
□ No □ Yes _______________________
Has your child had any hospitalizations since your last office visit?
□ No □ Yes _______________________
Please describe any other changes to your family history or social history here:
□ None
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medications your child is currently or recently on including over the counter and prescription: __________________________________
____________________________________________________________________________________________________________
Did they finish the full prescription? □ Yes □ No If No, when did they stop it?_____________________________________________
Briefly, describe your child’s current symptoms:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
REVIEW OF SYSTEMS: If your child is experiencing or has recently experienced any of the following, please mark below:
General
Ears
Urinary
Nervous System
□ Fever: ___________°F □ Ear Pain
□ Pain
□ Fainting
□ Weight loss
□ Poor hearing
□ Blood in urine
□ Blackouts
□ Weigh gain
□ Ringing in ears
□ Urgency
□ Seizures
□ Fatigue
□ Dizziness
□ Incontinence
□ Paralysis
Skin
□ Infection
□ Bed wetting
□ Local weakness
□ Rash
□ Discharge
□ Infections
□ Numbness
□ Swelling
□ Excess ear wax
□ Frequency
□ Tingling
□ Dryness
Noses/Sinuses
□ Urinating less
□ Tremors
□ Itching
□ Runny Nose
Endocrine
□ Memory
□ Eczema
□ Nasal stuffiness
□ Heat intolerance
Mind
□ Color change
□ Allergies
□ Cold intolerance
□ Nervousness
□ Infection
□ Nosebleeds
□ Excessive sweating
□ Lack of concentration
□ Change in hair
□ Sinus trouble
□ Excessive thirst
□ Memory issues
□ Change in nails
□ Color_____________ □ Excessive hunger
Emotions
Blood
Mouth/Throat
□ Excessive urination
□ Mood swings
□ Abnormal blood test
□ Cavities
Circulation
□ Depression
□ Bleed easily
□ Cold sores
□ Leg cramps
□ Excess anger
□ Bruise easily
□ Hoarseness
□ Cold extremities
□ Sadness
□ Anemia
□ Sore throat
Digestion
□ Frustration
Head
□ Blisters
□ Excess □ Belching
□ Mania
□ Headache
Lungs
□ Bloating
□ difficulty feeling or expressing emotions
□ Head Injury
□ Cough
□ Passing Gas
Neck
□ Wheezing
□ Trouble swallowing
Please list other:
□ Swollen nodes
□ Shortness of breath
□ Heartburn
_____________________________________
□ Stiffness
□ Difficulty breathing
□ Nausea
□ Pain
Heart
Appetite □ increased
_____________________________________
Eyes
□ Heart murmur
□ Decreased
□ Poor vision
□ Palpitations
□ Vomiting
_____________________________________
□ Blurry vision
Musculoskeletal
□ with blood
□ Sensitive to light
□ Joint pains
□ Abdominal pain
_____________________________________
□ Pain
□ Stiffness
□ Constipation
□ Redness
□ Backache
□ Diarrhea
□ Discharge
□ Muscle pain or
□ Blood in stool
□ Excess tearing
cramps
□ Change in bowel habits
□ Double vision
Stools □ pale □ black
□ Infections
Office Use Only:
B/P __________ P _________ R _________ Pulse Ox __________ Temp __________ HT _________ WT _________