Preview Patient Intake Form

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

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:

__________________________________________________________________________________________

_____________________________________________________________________________________________________________

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