Columbus Integrative Family Medicine Center Intake Form

Transcription

1 Columbus Integrative Family Medicine Center Intake Form Name: Today's Date: Birthdate: How did you hear about us? (Circle all that apply) Doctor Family Member Friend Internet Other What is your goal(s) for this visit? Symptom/Diagnosis When Did It Start? Frequency Severity (1 = mild, 10 = severe) How did you tried to resolve the above symptoms/diagnoses? Symptom/Diagnosis What did you try? How did it work? Please bring this form to your office visit, mail and or fax before your visit to Columbus Integrative Family Medicine Center 453 Waterbury Ct, Gahanna OH What complementary/alternative medicine modalities have you tried in the past? (Circle all that apply)

2 Acupuncture/Traditional Chinese Medicine Ayurveda Chiropractic Massage Naturopathy Homeopathy Other: Where were your ancestors living years ago? (ex., Americas, Europe, Asia, Africa) Maternal: Paternal: Do you have a family history of: Cancer Heart Disease Diabetes Arthritis Neurological Mental Illness Dementia Addiction Other Prior Diagnoses (if more than 5 please attach list) Date Treatment Prior Surgeries (if more than 5 please attach list) Type of Surgery Date Taking any medications, vitamins, herbs, supplements? Yes No

3 Name Dose Frequency (if more than 5 please attach list) Any medications allergy? Yes No Name Reaction Do you currently have any of the following, circle each that apply and check Yes or No Constitutional Dizziness, passing out, seizures, fatigue Yes No Eyes Eye problems (vision changes, dryness, floaters) Yes No ENT Ear problems (hearing, wax, ringing, pain) Yes No Nose problems (breathing, stuffiness, sense of smell) Yes No Throat problems (sore throat, difficulty swallowing) Yes No Mouth Mouth problems (pain, dental, sores, sense of taste) Yes No Cardiovascular Heart problems (heart attack, heart rate, blood pressure) Yes No Vein, circulatory problems (varicose, edema, blockage) Yes No Respiratory Lung disorders (asthma, breathing difficulty, emphysema) Yes No Gastrointestinal Digestive concerns (pain, bloating, indigestion, reflux) Yes No

4 Diarrhea or Constipation, number of bowel movements daily Genitourinary Kidney, urination (frequency, pain), genital problems Yes No Get up at night to urinate, number of times each night Musculoskeletal Bone, joint, structural problems, arthritis Yes No Recent wounds, injuries, pain, muscle cramps, spasms Yes No Skin Skin problems (dryness, rash, bumps, wounds) Yes No Neurologic Numbness, tingling, hands and feet cold in winter Yes No Forgetfulness, mental clarity, memory Yes No Mental Health Mood, depression, affect, sadness, grief, anxiety Yes No Hematology/Lymph Blood disorders, hepatitis, HIV/AIDS, herpes Yes No Allergy/Immune Allergies, Lupus, Scleroderma, immune disorders Yes No Endocrine Thyroid problems, Diabetes, low sugar, under/overweight Yes No How is your appetite? Good Excellent Poor, why? How often do you eat? 3 meals + snacks/day 3 meals 1-2 meals Snack only How often do you skip meals? Never Daily Occasionally, why How satisfied are you with your eating habits? Not at all Somewhat Very How satisfied are you with your currant weight? Not at all Somewhat Very Diet and Supplement Use Do you consider your diet to be healthy? Yes No why, Are you on a special diet? Yes No why, Do you have food allergies? Yes No why, Education, Exercise and Life Style: What is your highest level of education completed? Grade School High School Some College College Graduate School Other With whom do you live? Spouse Partner Parent Sibling Roommate Children Other Are you satisfied with your currant living situation? Yes No

5 Do you feel you have an adequate support system? Yes No How do you spend your free time? (Interests/Hobbies) What is your currant occupation? Years Are you satisfied with your occupation/employment status? Yes No Any Toxic Chemical Exposures in past? Yes, what, when, where No When in your life did you last feel well? What was different then? Do you exercise? Yes, how often week Minutes No, why not What is your exercise level? Scale 1-10 ( 1 low, 10 high) Do you use: Medications to aid sleep? Tobacco products? Alcohol? Mood-altering drugs? Pain Medications? If yes, have you tried to cut down on your use of these substances? Yes No Does it bother you when anyone questions your use of these substances? Yes No Do you ever feel guilty for using these substances? Yes No Have you ever used these substances to steady yourself in the morning? Yes No Have you ever sought counseling or professional help? Yes No Did you find it helpful? Yes No, why not Are you currently working with a counselor, therapist, clergy or life coach? Yes No If Yes, which profession and for how long? What are your major stressors?

6 How do you handle stress? Poorly Fair Good Well How is your memory? Poor Fair Good Excellent How clear is your thinking? Poor Fair Good Excellent Your rate of overall functioning? Poor Fair Good Excellent In the space allotted, you may provide any additional health concerns or most pressing issues: