Patient Intake Form
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Date: Insurance: (dd/mm/yr) Date of Birth: □ male □ female Address: Marital status S M W D SEP Phone : home: work: E-mail address: Occupation: Employer: Check and indicate the age when you had any of the following: General □ Allergies □ Depression □ Dizziness □ Fainting □ Fatigue □ Fever □ Headaches □ Loss of sleep □ Mental illness □ Nervousness □ Tremors □ Weight loss / gain Muscle / Joint □ Arthritis / rheumatism □ Bursitis □ Foot trouble □ Muscle weakness □ Low back pain □ Neck pain □ Mid back pain □ Joint pain Skin □ Boils □ Bruise easily □ Dryness □ Hives or allergies □ Itching □ Rash □ Varicose veins Eye, Ear, Nose Throat □ Colds □ Deafness □ Ear ache □ Eye pain □ Gum trouble □ Hoarseness □ Nasal obstruction □ Nose bleeds □ Ringing of the ears □ Sinus infection □ Sore throat □ Tonsillitis □ Vision problems Gastrointestinal □ Abdominal pain □ Bloody or tarry stool □ Colitis / Crohn’s □ Colon trouble □ Constipation □ Diarrhea □ Difficult digestion □ Diverticulosis □ Bloated abdomen □ Excessive hunger □ Gallbladder trouble □ Hernia □ Hemorrhoids □ Intestinal worms □ Jaundice □ Liver trouble □ Nausea □ Painful deification □ Pain over stomach □ Poor appetite □ Vomiting □ Vomiting of blood Genitourinary □ Bed-wetting □ Bladder infection □ Blood in urine □ Kidney infection □ Kidney stones □ Prostate trouble □ Pus in urine □ Stress incontinence Urination □ Overnight more than twice □ More than 8x in 24hrs □ Decreased flow/force □ Painful urination □ Urgency to urinate Cardiovascular □ High blood pressure □ Low blood pressure □ Hardening of the arteries □ Irregular pulse □ Pain over heart □ Palpitation □ Poor circulation □ Rapid heart beat □ Slow heart beat □ Swelling of ank
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