Patient Intake Form

PATIENT INTAKE FORM Name: ______Phone: Home: ______Work/Mobile: ______Street: ______Age: ______Ht: ______Wt: ______City: ______DOB: _____/______/______Male Female State: ______ZIP: ______Occupation: ______Marital Status: ______Primary Physician: ______Referred by: ______Emergency Contact/Relation: ______Emergency #: ______E-Mail address: ______

MAIN PROBLEM

PAST MEDICAL HISTORY - Including date Significant Illness: Cancer Diabetes High Blood Pressure Heart Disease Hepatitis Rheumatic Fever Thyroid Disease Seizures HIV Other ______Surgeries:______Significant Trauma: (auto accident, falls, etc.) ______Birth History: (prolonged labor, forceps delivery, etc.) ______Allergies: (drugs, chemicals, foods)______Medicines: (in the last 2 months i.e. OTC drugs, vitamins, herbs, etc.) ______Occupational Stresses: (chemical, physical, psychological, etc.) ______Family Medical History: Cancer Diabetes High Blood Pressure Heart Disease Hepatitis Stroke Asthma Allergies Alcoholism Seizures HIV Other ______Daily diet: Morning: ______Afternoon: ______Evening: ______Habits: Cigarettes Vape Coffee Tea Cola Alcohol Drugs Sugar Salt Other ______

MEDICAL HISTORY - Please Check All That Apply GENERAL Poor appetite Heavy appetite Poor sleep Heavy Sleep Insomnia Fatigue Tremors Vertigo Cold hands Cold feet Cold back Cold abdomen Fevers Cravings Night sweats Sweat easily Chills Localized weakness Poor coordination Change in appetite Sudden energy drop Peculiar tastes/smells Strong Thirst Bleed or bruise easily Other: ______SKIN & HAIR Rashes Ulcerations Hives Itching Eczema Pimples Dandruff Loss of hair Change in hair, skin texture Purpura Boils Tumors, Masses or Lumps (where) ______Other: ______2019.10 CONT’D

HEAD & NECK Dizziness Concussions Poor vision Glasses/Contacts Eye strain Eye pain Blurry vision Night blindness Color blindness Cataracs Nose bleed Sinus problems Ringing in ears Poor hearing Dry mouth Copious saliva Earaches Dry throat Grinding teeth Facial pain Tooth problems Jaw clicks Recurrent sore throats ______/months Sores on lips or tongue Headaches/Migraines (where/when) ______Other ______CARDIOVASCULAR High blood pressure Low blood pressure Chest pains Irregular heart beat Dizziness Swelling in hands/feet Cold hands/feet Phlebitis Blood clots Difficulty breathing Heart Medication Other ______RESPIRATION Asthma Bronchitis C.O.P.D. Pneumonia Cough Coughing blood Tight chest (how often) ______Production of phlegm (Amt/Freq): ______Color: ______Consistency: ______Other ______GASTROINTESTINAL Nausea Vomiting Diarrhea Black stool ______Frequency Bowel Movement Gas Belching Hemorrhoids ______Color Bad breath Rectal pain Pain or cramps Sensitive abdomen ______Odor Constipation Bloody stools Laxative use. Frequency of use: ______Other ______MUSCULOSKELETAL Neck pain (where): ______Muscle pain (where): ______Back pain (where): ______Joint pains (where): ______Other ______NEUROPSYCHOLOGICAL Seizures Areas of numbness Poor memory Concussion Depression Anxiety Bad temper Easily stressed Considered/attempted suicide Treated emotional problems: ______Other ______PREGNANCY & GYNECOLOGY Vaginal discharge Vaginal Sores Breast Lumps Pregnancy (#) ______Miscarriage (#) ______Premature (#) ______Births (#) ______First menses (age) _____ Period (duration) ______Clots Irregular periods Last menses ______Menopause (year) _____ Last PAP(date)______Normal/Abnormal Changes in body/psyche prior to menstruation ______Flow (describe)______Birth control type & duration______Other ______