ADULT INTAKE FORM. Date of 1st Appointment: How did you hear about me? Name: Address: Home Phone: Work: Cell:
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1 ADULT INTAKE FORM Date of 1st Appointment: How did you hear about me? Name: Address: City: Postal Code: Home Phone: Work: Cell: Where should I leave messages relating to your visits? Would you like to sign up for my list? Y / N Date of Birth: Age: Male/Female Occupation: Employer Hours per week Shift Work: Y / N Emergency Contact Name: Phone: Relation: Relationship Status: Married / Separated / Divorced / Widowed / Single / Partnership Live with: Spouse / Partner / Parents / Children / Friends / Pet / Alone Name of Spouse/Partner: Name & ages of children if applicable:: Are you currently pregnant or breastfeeding? Y / N OTHER HEALTH CARE PROVIDERS TYPE OF PROVIDER: Family Doctor Dentist Eye Doctor Other: Other: Other: Name: Mailing Address: Date last seen HEALTH CONCERNS Please list in order of importance, which health areas you would like to improve: Chief concerns: Associated symptoms: How long has it been going on? Diagnostic tests, diagnosis given: Previous treatments & results: 4. 1
2 What are your short-term health goals? What are your long-term health goals? CHRONOLOGICAL HEALTH HISTORY: Mother s state of health during her pregnancy, if known: How was your birth? Any complications? Please indicate below any accidents, injuries, illnesses, hospitalizations, surgeries, complications and any significant stressful event, emotional stresses or traumas (deaths, loss of job, divorce, etc.): Age 0-4 Age 5-9 Age Age Age Age Age Age Age Age Age Age Age Age Age 71+ Are any of these continuing to impact your life? MEDICAL HISTORY: How would you describe your general state of health? Excellent / Good / Fair / Poor Please indicate your energy level (1-10; 10 being the greatest): in the morning mid-day evening: VACCINATION HISTORY Please indicate what immunizations have you had: Small pox Polio MMR (measles, mumps, rubella) Hepatitis A Hepatitis B Haemophilus influenza B Flu Did you experience any adverse reactions? DPT (diphtheria, pertussis, Tetanus booster tetanus) Chicken pox Other 2
3 DENTAL HISTORY Do you have any of the following? Amalgam (silver) fillings Dental implants Root canal MEDICATION HISTORY: List any prescription or over-the-counter medications that you are presently taking. Name of Medication Daily Dosage For How Long? Reason for Taking OFF Drug category 4. Antibiotic use: When taken: For How Long? For what condition: List any nutritional/herbal supplements that you are presently taking: 4. Name Brand Daily Dosage For How Long? Reason for Taking O Do you frequently use: Aspirin/Tylenol/Advil/Laxatives/Antacids/Cortisone/Diet pills/hormones/birth control/sedatives Alcohol drinks/week: Tobacco amount/day: Caffeine amount/day: Recreational drugs: FAMILY HISTORY: Indicate if a close relative (parent/ child/ sibling) has had any of the following: Arthritis Cancer Dementia Anemia Diabetes Thyroid Seizure Allergies/ Kidney Skin Condition condition Disorder Asthma Disease Depression/ Drug/alcohol Autoimmune Digestive High Blood mental illness abuse Disease Disorder Pressure Other: I don t know my family history. 3
4 ALLERGIES Are you allergic or sensitive to: Any drugs/medications? Any foods? Any environmental triggers? Any chemicals? Any supplements? REVIEW OF SYSTEMS: Please Check The Box Of Or Circle Any Conditions That You Have, And Fill In The Blanks HEAD & NECK EYES & EARS NEUROLOGICAL GASTROINTESTINAL headaches light sensitivity dizzy/faint/seizures anemia migraines red/dry/itchy tremors/tics heartburn/gas/bloating swollen nodes tearing numbness/tingling belching/flatus stiffness blurred vision muscle weakness nausea NOSE & SINUSES floaters/spots in vision balance/speech problems excess/poor appetite frequent infections ringing in ears RESPIRATORY excess/poor thirst stuffiness CARDIOVASCULAR wheezing diarrhea/toxic odour hay fever palpitations coughing/sputum constipation sinusitis chest pain shortness of breath rectal bleeding/itch Post Nasal Drip high blood pressure asthma hemorrhoid/fissure obstruction/snoring swollen ankles GENITOURINARY # BMs/day: ENDOCRINE PERIPHERAL VASCULAR difficulty stopping/starting/ incontinence blood/mucus/food in stool hormone use cold hands/feet excessive urination stools loose/formed thyroid issue varicose veins reduced flow hard stool/strain fatigue IMMUNOLOGICAL urgency/frequency SKIN diabetes/hypoglycemia cancer/mononucleosis kidney stones hives/eczema/psoriasis/rash excessive/no sweat autoimmunity dark/cloudy urine acne/warts/boils/moles 4
5 MUSCULOSKELETAL FEMALE REPRODUCTIVE Other: BREAST HEALTH muscle/joint pain If still menstruating: age of 1st menses: fibrocystic/lumps arthritis cycles begin every days age of menopause: sore breasts muscle spasms/ cramps osteopenia/ osteoporosis irregular cycles # pregnancies: self examination heavy/light flow/clots # live births: MALE REPRODUCTIVE PSYCHO/SOCIAL cramps/endometriosis difficulty conceiving hernias depression/sad PMS: abnormal PAP sores/lumps history of abuse tender breasts yeast infections discharge addiction cravings vaginal itch/discharge prostate problems phobias/fears/ compulsions acne STD disinterest in sex mood swings/anger bloating painful intercourse erectile dysfunction anxiety/panic/ emotional lability vaginal dryness low sperm count nervousness disinterest in sex learning disability headache fibroids/cysts STD DIET: How many glasses/mls of water per day do you drink? Are there any foods or food groups that you avoid? Y/N If yes, which ones and why? Food cravings: Do you choose organic food? Y/N What types? Do you consume freshwater fish? Y/N What types? Tap Bottled Filtered How much of the following do you consume on a weekly basis?: wheat products (breads, pastas, pastries, etc.) dairy products (milk, cheese, yogurt etc) processed/ prepared foods luncheon/smoked meats carbonated beverages candy/sweets margarine/ vegetable oils artificial sweetener fast food plastic wrap microwaved food coffee/tea 5
6 Do you cook your own meals? Y / N # of days per week you eat out: Do you eat three meals a day? Y N Describe a typical day s diet: Breakfast: Lunch: Dinner: Snacks: Beverages: LIFESTYLE: How often do you get outside?< 1/wk < 1-3/wk < 3-5/wk < >5/wk How often do you engage in physical activity? < 1/wk < 1-3/wk < 3-5/wk < >5/wk What type of activities, and at what intensity? Do you have any difficulty falling asleep? Y/N Do you wake during the night? Y/N If yes, how often? Do you feel well-rested when you wake up? Y/N How many hours of sleep do you get at night? Is it enough? Do you have a religious or spiritual practice? Y/N If yes, what? Do you read? Y/N How many hours per week? Do you enjoy your work? Y/N Do you take vacations? Y/N Have you traveled outside of Canada in the last 5 years? Y/N If yes, when and where: Have you been camping in the last 5 years, or do you go camping frequently? Y/N ENVIRONMENT: Please describe your home: location, new/older construction, damp/moldy, etc. Do you have specialized air filtration at home? Y/N Do you live in the city or country? Do you work in an office building? Y/N Do the windows open? Y/N Are you currently exposed to second hand smoke? Y/N Have you ever been exposed to toxic chemicals, solvents, pesticides, herbicides, metals, (lead, mercury, cadmium, arsenic, etc.) at home, work or traveling? Y/N Are you exposed to toxins and other hazards, Electro-Magnetic Fields, or loud noise (work, home, hobbies, etc.)? Y/N Please describe. How would you describe the emotional climate of your home? Are you sexually active? Y/N Preference: Heterosexual Bisexual Homosexual Do you use birth control? Y/N If yes, what type? Are you in a happy, supportive relationship? Very Mostly Somewhat Not Rate your stress level (please circle): Minimal Average High Very high Unbearable What areas of your life contribute most to your stress?: Work Health Family Financial Interpersonal Spiritual Unfulfilled expectations Other How well do you handle these stresses? What do you do to deal with stress? When was your last vacation? How often do you take one? 6
7 What do you enjoy most in your life? What are your main interests or hobbies? What do you worry about most in your life? What nurtures you? On a scale of 0-10, how satisfied are you with the following areas of your life? (0 being not satisfied, and 10 being extremely satisfied) Career/Work Family Personal Growth Health Friends Money Love Physical Environment Fun/Recreation Diet Lifestyle COMMITMENT: The primary goal of naturopathic medicine is to identify and address the underlying cause of symptoms. Treating the root of illness and maintaining health does not occur overnight; healing is a process that takes time. It requires commitment to making lifestyle changes and following treatment protocols. On a scale of 1-10, how would you describe your level of commitment at this time? (0=not committed, 10=fully committed) What behaviours or lifestyle habits do you currently engage in that you believe support your health? Please list. What behaviours or lifestyle habits do you currently engage in that you believe are destructive to your health? Please list. What potential obstacles do you foresee in addressing the lifestyle factors that are undermining your health and in adhering to the treatment plan that you & I will be creating? Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making? What expectations do you have of me personally as your physician? Is there anything that you feel is important that has not been covered? Thank-you for filling out this lengthy questionnaire; It will help me get to know the whole person and determine the root cause of your concerns. All information is confidential. Elly 7
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Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
ADULT CLIENT INFORMATION SHEET Date of Initial Appointment:
Dr. Han Ping Helen Cen, ND ADULT CLIENT INFORMATION SHEET Date of Initial Appointment: Name: Birthday: Address: City: Province: Postal Code: Home Phone: Cell: Work: Email: Appointment Notifications: We
Adult Intake Form. In case of emergency, contact: Relationship: Phone:
Personal Information Date: Adult Intake Form Name: Sex: M F Age: Birth Date: Address: City: Province Postal code: Telephone (Home): (Work): (Cell): Email: Preferred contact for appointment reminders: email
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Amarillo Surgical Group Doctor: Date:
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Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
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NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM
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New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4
New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4 Date: Name Age Date of Birth Address Postal Code Occupation Phone (home) (work) Okay to leave a message?
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
Patient Intake Form for Acupuncture Treatment at Infinite Healing
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Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)
Comprehensive Cancer Center A Cancer Center Designated by the National Cancer Institute Please answer the following questions and bring this form to your first appointment at Rutgers Cancer Institute of