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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 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:_______________________________________________________Of Above please circle how do you prefer to be contacted?

Date of Birth:____________________
Weight:____________ Height:_________
Weight 1 year ago:___________
Maximum weight: ________ When___________
Occupation:__________________________
Family status (married, single, living with partner)with or without children?
_________________Blood Pressure: high____ low___

High cholesterol: __yes __no

Check how often you have a bowel movement?
Once a day     Twice a day   More than twice a day   Once every two days                       Once a week     Longer than a week apart  
Is there anything unusual about your bowel movements? (color, shape, texture, amount)
____________________________________________________________
Body Temperature:   hot     cool     varies
What season/climate do you prefer?___________
Please list any foods that you crave:______________________________________

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 drink a day?_____________________________        

How often have you been tested for tuberculosis? Yes   No
Was it positive? Yes   No
How often have you taken a course of antibiotics in the past 2 years?_____________
Do you have any sensitivities to pharmaceutical drugs? Please list.

What vaccinations have you had?___________________________________                         Have you ever reacted negatively to a vaccine? Yes   No
If yes, what was your reaction?_____________________________________

Please check off any of the following that apply to you:
[] Use of tobacco []contact tobacco smoke [] use “recreational” drugs
[] Use alcohol [] use caffeinated beverages [] face excess stress
[] Diet often [] eat three meals a day [] become exposed to chemicals
[] Sleep well [] wake rested [] average 6-8 hours sleep
[] Enjoy your work [] take vacations [] watch television
[] Exercise regularly: Form(s) of Exercise________________________________ []do not exercise regularly

Have you had any of the following medical conditions?
[] Sunstroke []Tuberculosis []Whooping Cough
[] Stroke []Typhoid fever [] Yellow Fever
[] Syphilis [] Warts

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.

List any surgery you have had__________________________________

Please check off any of the following that apply to you:
[] Use of tobacco []contact tobacco smoke [] use “recreational” drugs
[] Use alcohol [] use caffeinated beverages [] face excess stress
[] Diet often [] eat three meals a day [] become exposed to chemicals
[] Sleep well [] wake rested [] average 6-8 hours sleep
[] Enjoy your work [] take vacations [] watch television
[] Exercise regularly: ____ what forms:__________ []do not exercise regularly

Have you had any of the following medical conditions?
[] Sunstroke []Tuberculosis []Whooping Cough
[] Stroke []Typhoid fever [] Yellow Fever
[] Syphilis [] Warts

Any other medical conditions?______________________________________________
Have any of the above listed conditions any members of your family? If so, indicate their relation to you (e.g. mother, brother, aunt, grandparent, child, etc).

Attention Veterans:

This Practice Is Now Registered with the Veterans Choice Program under Health Net

The Senate approved a bill the President signed into law authorizing $5.2 billion to extend the current Veterans Choice Program for one year while the VA enacts reforms to expand private care options. Here is a Link to the description of the VA Mission Act