HTML Preview Patient Intake Form page number 1.


Check and indicate the age when you had any of the following:
Patient Intake Form
Patient information contained within this form is considered
strictly condential.
Your responses are important to help us better understand
the health issues you face and ensure the delivery of the
best possible treatment.
Name: ________________________________ Date: _________
Insurance: ____________________________________ (dd/mm/yr)
Date of Birth: ____________________________
Address: ________________________________
________________________________
_________________________________
Phone #: home: _________________ work: ____________________
E-mail address: ___________________________________________
Occupation: _________________ Employer: ___________________
□ male □ female
Marital status
S M W D SEP
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 ankles
Respiratory
Chest pain
Chronic cough
Difficulty breathing
Hay fever
Shortness of breath
Spitting up phlegm / blood
Wheezing
Women only
Congested breasts
Hot flashes
Lumps in breast
Menopause
Vaginal discharge
Menstrual flow
Reg. Irreg. Pain / cramps
Days of flow: ____ Length of cycle: _____
Date - 1
st
day last period: ______________
Are you pregnant?
yes,no
If yes, how many months? _____
How many children do you have? _____
Birth control method: ________________
Date of last PAP test: ________________
normal, abnormal
Date of last mammogram: ______________
normal, abnormal
Check any of the conditions
you have or have had:
Alcoholism
Anemia
Appendicitis
Arteriosclerosis
Asthma
Bronchitis
Cancer
Chicken pox
Cold sores
Diabetes
Eczema
Edema
Emphysema
Epilepsy
Goiter
Gout
Heart burn
Heart disease
Hepatitis
Herpes
High cholesterol
HIV/AIDS
Influenza
Malaria
Measles
Miscarriage
Multiple sclerosis
Mumps
Numbness/tingling
Pace maker
Osteoporosis
Pneumonia
Polio
Rheumatic fever
Stroke
Thyroid disease
Tuberculosis
Ulcers
Please list any medication you are currently taking and why:
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Reproduction is permitted for personal use, not for resale or redistribution. www.prohealthsys.com ©2012 by Professional Health Systems Inc. “Dedicated to Clinical Excellence.”
DOWNLOAD HERE


Leadership is a potent combination of strategy and character. But if you must be without one, be without the strategy. | Norman Schwarzkopf