Health Intake Form
Please print & fill out health intake & informed consent form and bring them with you at the time of your initial appointment. To prepare for your initial 75-80 minute consultation and treatment please wear comfortable clothing. Please refrain from wearing cosmetics and perfume as this helps me with my diagnosis. I look forward to working with you to address your health issues.
Patient Name_____________________________________________
Address:________________________________________________
Home Phone:_________________ Cell Phone:____________________
Email:_______________________________________________________ Circle how do you prefer to be contacted?
In case of emergency, contact_____________________________ Relationship_______________Phone#______________________. How did you hear about us?_________________________
If you were referred who referred you?__________________________
Date of Birth:____________________
Weight:____________ Height:_________
Weight 1 year ago:___________
Maximum weight: ________ When___________
Occupation:__________________________
Family status (married, single, living with partner)with or without children?
All Information will be kept strictly confidential.
Describe the chief (s) complaint 1._____________________________________________________________________ _______________________________________________________________________ When did this start?_______________________________________________________ 2.______________________________________________________________________ _______________________________________________________________________ When did this start?_______________________________________________________ 3.______________________________________________________________________ ________________________________________________________________________ When did this start?________________________________________________________
Have you been treated for this (these) condition(s) or consulted any other health care professional? If so what was the diagnosis?
FEMALE PATIENTS:
Age of first period:_________
Average # of days menstruating:____ Average # of days in a normal period:____ Number of pregnancies:____
Age at first pregnancy:___
Number of births:____ _____cardiac complications _____palpitations _____shortness of breath ___None _____other. Blood Pressure: high____ low___ High cholesterol: __yes __no Frequency of a bowel movements
Once a day[] Twice a day[] More than twice a day[] Once a week[]
Longer than a week apart [] Once every two days []
Is there anything unusual about your bowel movements? (color, shape, texture, amount)
Body Temperature: Do you run hot[] cool []
What season/climate do you prefer?
Please list any foods that you crave: Are there any specific foods you crave around your menstrual cycle?
Are there any foods you desire or are averse to?
Do you have any specific dietary restrictions? Do you have any known food sensitivities?
How many glasses of water do you consume daily? Tested for tuberculosis? Yes[] No[] Was it positive? Yes[] No[].
How often have you taken a course of antibiotics in the past 2 years?
List any sensitivities to pharmaceutical drugs.
What vaccinations have you had?
List negative reactions to a vaccine:
List Surgeries and year(s)
Surgery Complications (if any)
List major injuries & year
Long Term Effects (if any
Please check off any of the following that apply to you:
[] Use of tobacco [] Use alcohol
[] Diet often [] Sleep well
[] Enjoy your work
[] Exercise regularly
[]contact tobacco smoke
[] use caffeinated beverages [] eat three meals a day [] wake rested
[] take vacations.
[] use “recreational” drugs [] face excess stress
[] become exposed to chemicals
[] average 6-8 hours sleep [] watch television or on social media. Hours of use_____
[]do not exercise regularly
Have you had any of the following medical conditions?
[] Sunstroke [] Stroke
[] Syphilis
[]Tuberculosis []Whooping Cough []Typhoid fever [] Yellow Fever
[] Warts
List any other medical conditions?
Have any of the above listed conditions afflicted or led to the death of any members of your family? If so, indicate their relation to you (e.g. mother, brother, aunt, grandparent, child, etc) and their age at the time of their death.
SLEEP Quality Please check all that apply:
Excessive need for sleep Insomnia or anxious sleep []Never []Occasionally [] Often [] Daily Erratic sleep, insomnia or disturbing dreams []Never []Occasionally [] Often [] Daily
Insomnia when nervous or excited
[]Never []Occasionally [] Often [] Daily
Excitement, anxiety & fatigue cause light, restless sleep & vivid dreams or nightmares.[]Never []Occasionally [] Often [] Daily
