Initial Patient Intake Form

INITIAL PATIENT INTAKE FORM When completing this Patient Intake Form, please provide as much detail as you can give as the additional information is very helpful in understanding your health. Record all food and drink for three days prior to the visit. Bring medical or lab reports that that are relevant and any medicines you are taking. Also, bring your insurance card. THIS INFORMATION IS PART OF YOUR MEDICAL RECORD, AND BY LAW, CANNOT BE RELEASED OR DISCLOSED WITHOUT YOUR PERMISSION: Name: _______________________________________ M/F: ___ Address: _________________________________ Telephone No. Home: ______________ Work: ______________ Birthdate: _____________ Age: _________ Weight: ______ Ideal Weight: ________ Height: ________ Insurance: __________________ Private Pay: _______________________________ Insurance No: ____________________________ GROUP NO: _____________ Other Medical or Health Providers you have seen within the last 5 years: ___________________________________________________________________ PAYMENT: Payment or insurance billing information is due at the time of initial visit. If you need to schedule payment or are having difficulty with payment, please contact the provider. I. MEDICAL REASON(S) FOR VISIT What is the medical reason for your visit? _____________________________________________________________________ How long have your had this condition? _____________________________________________________________________ Current RX/Herbs/Homeopathic Vitamins: _____________________________________________________________________ Significant Health Problems: In chronological order

_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ALLERGIES: (Food, MEDICATION, Environmental) Present or Previous: MEDICATION: ____________________________ FOOD: _________________________ ENVIRONMENT: __________________________ OTHER: ________________________ How long have your had them? _____________________________________________________________________ What do you take for them? _____________________________________________________________________ How do your allergies affect you? _____________________________________________________________________ II. REVIEW OF SYSTEMS Headaches? Location: (front, sinus, temple, etc. How often? When? What makes them better? How makes it worse? Intensity of pain? Days better? Season better? FOR THE FOLLOWING QUESTIONS: Please check off yes or no if you have problems in the following areas. If yes, briefly describe. Sinus: Sinus tenderness? Eyes? Ears? Nose? Throat? Teeth? Bad / sour breath? Fillings? Mercury? Silver? Throat? Thyroid? Chest? Breast? Stomach? Liver? Spleen? Bowel Movements? How often? Consistency?

Gas (flatus)? Rectum? Women: Vaginal Problems? Problem with menstrual flow. Frequency? Menstruation heavy? Light? Contraception use? STD? Men: Genital Testicular Exam: Prostate: (PSA/PAP) OINTS: Arms: _____ Shoulder: _____ Legs Feet? ADDITIONAL PROBLEMS:___________ III. LIFESTYLE Stress Stress in your life? Your stress level? Scale of 1 - 10? Joy What gives you joy in life? What gives you pleasure in life? Do you have hobbies you enjoy? Do you live alone or with family/friends? Your joy level? 1 - 10? Sleep Any difficulty with sleep? Hours do you sleep? Do you awaken refreshed after sleeping? IV. FAMILY HISTORY Significant Family History of Illness: MOTHER: Alive:_____ Age: FATHER: Alive _____Age: SIBLINGS: Health: Age: Parents: Smokers? Alcohol or drug use in the family? History of congenital diseases in the family? Where are you in the birth order? What was the environment like as a child? Peaceful?

Happy? Tension?

Birth: Any unusual problems at birth? Premature? Other?

Conflicted?

Vaccinations: Significant Health Problems as a child? Social History Please fill out to your degree of comfort; this information is confidential and helpful. Do you have a consistent network of family or friends you can rely on for support? Personal use of alcohol: How often?

Amt.

Personal use of marijuana, drugs or narcotics? Past? __________ Present? __________ How often? __________ Amount? __________ Tobacco use: Sexuality: Are you involved in a satisfying relationship? EXERCISE: What do you like to do for exercise and how often? ____________________________________________________________________ V. ENVIRONMENT A. WORK What kind of setting do you work in? Home? _____ Office? _____ FACTORY? _____ Do you like your work? If not, what would you rather do? Any unusual problems with your work environment? Stress? Mechanical injury (carpal Tunnel)? At work do you get dizzy or have headaches? Any history of work related injuries? Detail? ____________________________________________________________________ B. HOME House? Apt? How long have you resided there? _________ Briefly describe your home? Dry :_____ Damp: _____ Moldy: _____ Sunny: _____ Dark: _____ Heating what kind? Woodstove? _____ Forced air? ______ A/C? _____

Do you live near: Factory? _____ Dry Cleaner? _____ Incinerator? _____ Power Station? _____ Do you use an electric blanket or heating pad? Is there an electric outlet at the head of your bed? C. ALLERGENS Do you own cats? Pets?

Do you sleep with them?

Home clean? Thoroughly vacuumed and or mopped at least once a week? VI. OTHER Use additional paper as necessary. This is the fun stuff. Now that you’ve worked so hard on completing this form, it’s time for some fun... Be as creative as you like. Draw a picture of yourself. (You can use a separate sheet of paper.) Mark where you hurt or have difficulties. Draw a picture of yourself as you would like to be in the future? If your illness or condition had a face, what would it look like? If it had a voice, what would it say?