<p>CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>Thank you for taking the time to fill out the overview form. This information will greatly assist us in helping you achieve your health and wellness goals. </p><p>All information is strictly confidential as required by law and our center’s privacy policy.</p><p>INTAKE FORM</p><p>Name: ______Date: ______Date of Birth: ______</p><p>Address: ______</p><p>Email: ______Occupation: ______Age: ______</p><p>Telephone Mobile: ______Home: ______</p><p>Emergency Contact Name: ______</p><p>Phone: ______Relation: ______</p><p>Spouse/ Partner Name: ______</p><p>Children Names & Ages: ______</p><p>How did you hear about the Cameron Wellness Center? ______</p><p>Health Information</p><p>Please list your health concerns in order of importance to you, and the date of onset:</p><p>1.</p><p>2.</p><p>3.</p><p>4.</p><p>5.</p><p>Please list your most stressful life experiences:</p><p>1. Age: ______</p><p>1 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>2. Age: ______</p><p>3. Age: ______</p><p>4. Age: ______</p><p>5. Age: ______</p><p>Supplements & Drug Medications</p><p>Please list all vitamins, minerals, herbs, and/or homeopathic remedies you are currently taking.</p><p>Supplement Dose/day How long Reason</p><p>Please list all medications you are currently taking (prescription and over-the-counter).</p><p>Medication Dose/day How long Reason</p><p>Are the medications well tolerated? Y N If no, please list the adverse reactions or side effects and from which medication:</p><p>In the last 10 years, approximately how many courses of antibiotics have you taken?</p><p>Medical History</p><p>Please indicate if you have had any of the following diagnostic tests performed:</p><p>Test Date Notable finding</p><p> Thyroid Panel</p><p>2 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p> Liver Panel</p><p> Complete blood count</p><p> Blood sugar test</p><p> Colonoscopy</p><p> Food Allergy</p><p> Heavy Metals</p><p> Digestive Stool Analysis</p><p> Cholesterol</p><p> Hormone level</p><p> EKG</p><p> Chest x-ray</p><p> Mammography</p><p> Thermography</p><p> Adrenal Function</p><p> Other</p><p>Date of last physical exam: ______Findings: ______</p><p>Please list any past surgeries or hospitalizations with approximate dates:</p><p>Please list all past injuries (i.e. broken bones, joint sprains, burns, falls, car accidents, etc.) with dates:</p><p>List all dental work and the approximate date of the procedure (root canal, mercury or ceramic filling, implants, caps, dentures):</p><p>3 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>Indicate if you have had any of the following:</p><p>Childhood Illnesses</p><p>O Asthma O Chicken pox O Eczema O Frequent ear infections or colds</p><p>O Measles O Mumps O Polio O Rubella </p><p>O Rheumatic fever O Scarlet fever O Whooping cough</p><p>Vaccination History</p><p>O Measles O Hepatitis A O Hepatitis B O Tetanus</p><p>O Small pox O Diphtheria O Mumps O Flu Shot</p><p>O Chicken pox O Pertussis O Rubella O Polio</p><p>O Shingles</p><p>Other Medical Procedures</p><p>O Joint replacement O Pacemaker O Pins or plates</p><p>What is your blood type? A+ B+ O+ AB+ A- B- O- AB-</p><p>Height: ______Current Weight: ______Weight 1 yr. ago: ______</p><p>Maximum weight: ______When? ______Desired weight: ______</p><p>Review of Systems</p><p>Circle if the symptom has occurred in the last year. Place a check mark if the symptom has occurred in the past.</p><p>General weight gain chronic fatigue night sweats intolerance to heat weight loss afternoon fatigue fever chills intolerance to cold significant wt. loss weakness sick more than 1 time/ yr cold hands/ feet significant wt. gain excessive thirst other: history of dieting anemia Skin dry skin acne athlete’s foot changes to nails itchy skin eczema moles changes to skin rashes psoriasis bumpy skin on back of arms color hives shingles spider/ varicose veins changes to moles moist skin ringworm nail fungus bruising easily nail ridges other:</p><p>4 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>Head headaches dizziness trauma other: migraines vertigo hair loss</p><p>Eyes dry eyes floaters cataracts vision correction: watery eyes blurred vision vision loss vision: near/ far itchy eyes impaired vision other: contacts eye pain double vision glasses red eyes eyes sensitive to light laser discharge from eyes poor night vision Ears ear pain discharge from ears ear infections hearing aids itchy ears ringing in ears ear infections as a child other: waxy ears hearing loss</p><p>Nose & Sinuses itchy nose post nasal drip breathes through mouth other: discharge from nose nosebleeds snores congested nose/sinuses loss of smell</p><p>Mouth & Throat dry mouth frequent sore throat dentures jaw clicks itchy mouth/throat coughing up blood inflamed/bleeding gums TMJ sores on mouth/lips persistent cough cavities treatment for strep hay fever/allergies difficulty swallowing braces as a child… bad breath loss of taste teeth sensitivity other: root canals hoarseness implants</p><p>Neck neck pain or stiffness swollen glands trauma other:</p><p>Respiratory shortness of breath asthma exposure to chemicals history of 2nd hand wheezing allergies exposure to solvents smoke pain w/ breathing bronchitis/pneumonia exposure to particulates other: chronic cough positive TB test coughing up blood history of smoking</p><p>Cardiovascular high blood pressure feel heart racing purple fingers/lips hemorrhoids low blood pressure chest tightness irregular heartbeat spider veins high cholesterol difficulty breathing at heart murmur calf pain at night high glucose night dizziness on standing calf pain walking chest pain palpitations exhaustion with minor exertion other: heaviness in legs swelling in ankles cold hands/feet heart fluttering</p><p>Circle if the symptom has occurred in the last year. Place a check mark if the symptom has occurred in the past.</p><p>Gastrointestinal poor appetite indigestion stool shape: intolerance to specific foods excessive appetite heartburn/antacid use -one piece fatigue after eating changes in appetite constipation (<1 stool/day) -hard little pellets food sensitivity excessive thirst stool hard to pass -breaks up in water anal itching trouble swallowing foul smelling stools -other: liver disease stomach pain loose stools (break up gallbladder disease nausea/vomiting when in water) Color: treated for parasites burping/belching diarrhea -yellow ulcers abdominal pain blood in stools -green hemorrhoids abdominal bloating black tar in stools -light brown other: gas/flatulence mucous in stools -dark brown undigested food in stools -black</p><p>5 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>Endocrine hypothyroid heat or cold intolerance poor appetite unexplained weight loss hyperthyroid diabetes excessive hunger easy weight gain hypoglycemia fatigue seasonal depression other: excessive thirst</p><p>Immune slow wound healing chronic fatigue syndrome chronically swollen chronic infections reactions to vaccinations glands other:</p><p>Neurological fainting head trauma loss of grip strength other: dizziness/vertigo poor concentration loss of muscle tone numbness or tingling memory loss muscle weakness trembling hands lack of alertness head heavy heavy extremities</p><p>Urinary frequent urination light yellow urine Kidney infections dripping after urination urinate <3 times/day yellow urine bladder infections bed-wetting can’t hold urine yellow dark urine urination at night other: urination with cough or red urine pain/burning urination sneeze cloudy urine strong smelling urine</p><p>Musculoskeletal pain in: painful bones chronic pain arthritis -arms tight shoulder muscles loss of height herniated/slipped disk -shoulders swollen knees/elbows unable to sit straight tendonitis -upper back numbness/tingling activities limited due to osteoporosis -hips burning pain broken bones -feet spasms/cramps other: -hands morning stiffness -neck -lower back -legs</p><p>Women Only Heaviest flow day: Sexually active Y N Age of first menses: # of pads/tampons on heaviest day: Which gender are you sexually active with? -Men -Women –Both Length of period: # pregnancies: Type of birth control: Length of cycle: # live births: Type of STD control: condoms/ monogamy/ other: Date of last menses:</p><p>Circle if the symptom has occurred in the last year. Place a check mark if the symptom has occurred in the past.</p><p>6 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>Women Only Clots with period Menstrual cramps Wt. gain with period</p><p>Spotting between periods PMS Irritability Moodiness Tendency to cry Bloating/swelling Breast tenderness Low back pain Fatigue with period Missed periods Irregular periods PMS Lack of sexual desire Vaginal itching Vaginal discharge Vaginal odor Yeast infections Vaginal mucosa dry Painful intercourse Painful masturbation History of STDs Y N Tested for STDs Y N Uterine fibroids Hysterectomy Use of birth control pills for Monthly breast self-exam Use of hormone Breast feed your child greater than 10 yrs? Y N replacement: Age of menopause: ____ # of mammograms Hot flashes Fibrous breast Breast implants Vaginal dryness Abnormal mammogram Difficulty conceiving</p><p>Changes in cycle Moodiness Menopause Nipple discharge Brain fog Ovarian cysts Other:</p><p>Men Only Sexually active? Y N Type of birth control: History of STDs Y N</p><p>Sense of full bladder Discharge from penis Testicular lump Difficult urinating</p><p>Sore on penis Breast lump Burning/pain w/ urination Wake up to urinate</p><p>Infertile Lack of sexual drive Sexual difficulties History of prostatitis</p><p>Enlarged prostate Prostate exam? Y N PSA test? Y N Prostate cancer</p><p>Increased straining w/ Hernias Other: urination</p><p>Please indicate whether any family members have had any of the following: (Include parents, siblings, maternal grandparents (MGP), paternal grandparents (PGP), aunts, uncles. Include age and cause of death if applicable.)</p><p>Relation to you Relation to you</p><p>O Alcoholism O Diabetes</p><p>O Allergies O Drug Abuse</p><p>7 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>O Alzheimer’s disease O Heart disease</p><p>O Arthritis O High blood pressure</p><p>O Asthma O Kidney disease</p><p>O Cancer (indicate type) O Osteoporosis</p><p>O Depression O Stroke</p><p>O Epilepsy O Anemia</p><p>O Autoimmune condition O Glaucoma</p><p>O Skin condition O Tuberculosis</p><p>O Thyroid condition O Other medical illness</p><p>Please list all allergies (food, medication, environmental):</p><p>Rate your stress level (1=low, 10=high) 1 2 3 4 5 6 7 8 9 10</p><p>Which factors most contribute to your stress?</p><p>O health O work O money O family O marriage</p><p>Please describe: </p><p>8 CAMERON 1945 S 1100 E Suite 100 801-486-4226 Wellness Center Salt Lake City, UT 84106 drtoddcameron.com</p><p>What brings you joy?</p><p>Any additional information about your health that you would like to share: </p><p>Thank you for taking the time to fill out the overview form. This information will greatly assist us in helping you achieve your health and wellness goals. All information is strictly confidential as required by law and our center’s privacy policy.</p><p>9</p>