Symptoms Data Collection Form -
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1 Symptoms Data Collection Form - Name Address City State Zip Phone ( ) Sex (m or f) Age Height: (feet) (inches) Weight (pounds) Number Bowel Movements / Week Occupation Blood Pressure / (helpful, but not required) Comments Practitioner 1
2 Check all symptoms below that repeat (daily, weekly, monthly) Daily Exercise Level: Little to no exercise Light exercise (1 3 days per week) Moderate exercise (3 5 days per week) Heavy exercise (6 7 days per week) Very heavy exercise (twice per day, extra heavy workouts) Symptoms that Repeat: 11. Get boils or sty s more than once per year 12. Throat infections more than once per year (sore throat 13. Cold sores, fever blisters more than once per year 14. Any infection with fever more than once per year 15. Swollen lymph glands more than once per year 16. Ear infections more than once per year 17. Slow to recover from cold or flu 18. Catch colds or flu easily 19. Lacerations (cuts become infected easily 20. Itchy nose 21. Itchy eyes 22. Itchy roof of mouth or throat 23. Clear watery nasal discharge 24. Headaches 25. Mucous in the throat 26. Post nasal drip 27. Discharge from the eyes 28. Puffiness under the eyes 29. Ear discharge or stuffed up 30. Nasal congestion 31. Running nose 32. Wheezing 33. Sneezing 34. Fatigue 35. Exposed to cigarette smoke 36. Exposed to mold 37. Sinus congestion 38. Food allergies or sensitivities 39. Skin rashes 40. Entire body aches, painful to touch 41. Swollen joints 42. Certain foods make you sick, nauseous, depressed, jittery 43. Painful stomach or intestine 44. Alternating constipation and diarrhea Swollen or itchy tongue or mouth 46. Difficulty in swallowing 47. Hyperactivity 48. Fatigue increases after eating 49. Exposed to chemicals or radiation at work 50. Eat luncheon meats containing nitrates or nitrites 51. Eat fruits and vegetables that contain pesticides 52. Eat foods that contain monosodium glutamate (MSG) 53. Use artificial sweeteners 54. Milk makes allergy symptoms worse 55. Pain in chest and left arm 56. Calf muscles cramp while walking 57. Heart palpitations 58. Feel jittery 59. Irregular heart beats 60. Swelling of feet and ankles 61. Fast heart beat 62. Exhaust with minor exertion 63. Light-headedness 64. General weakness 65. Smoke cigarettes/tobacco
3 66. Chew tobacco 67. More than 3 cups of coffee daily 68. High daily stress level 69. Cold hands and feet 70. Tingling or burning in hands and feet 71. Numbness in extremities 72. Skin sores of the legs or feet 73. Spider veins on nose or face 74. Ringing in ears 75. Poor concentration 76. Slurred speech 77. Salt foods without tasting 78. Exercise with low to moderate exertion 79. Exercise with high exertion (Aerobics 80. Vascular surgery 81. Chest pain without left arm pain 82. Tightness or pressure in the chest 83. Upper chest or neck itch 84. Chronic cough 85. Difficulty in breathing 86. Shortness of breath 87. Sensitive to smog / air pollution 88. Infections settle in lungs 89. Respiratory attacks that last hours to days 90. Bleeding gums or periodontal disease 91. Stomach pains after meals 92. Nausea 93. Dependency on antacids 94. Butterfly sensations in stomach 95. Difficulty in belching 96. Stomach pain when emotionally upset 97. Sudden, acute indigestion 98. Relief of stomach pain by drinking carbonated beverages 99. Relief of stomach pain by drinking cream or milk 100. History of ulcer or gastritis 101. Current ulcer or gastritis 102. Black stool while not taking iron supplements 103. Nervousness 104. White spots or lines on finger nails 105. Indigestion 1-3 hours after eating 106. Diarrhea 107. Roughage and fiber causes constipation 108. Mucous in the stools 109. Stool poorly formed 110. Shiny stool 111. Three or more large bowel movements daily Foul smelling stool 113. Dry skin or dry hair 114. Pain in left side of rib cage 115. Acne 116. Difficulty gaining weight 117. Dizziness when standing suddenly 118. Loss of vision when standing suddenly 119. Crave sweets 120. Crave carbohydrates 121. Headaches relieved by eating sweets or alcohol 122. Impatient 123. Moody 124. Irritable if a meal is missed 125. Wake up in middle of the night craving sweets 126. Poor memory 127. Feel faint 128. Calmer after eating 129. Frequent urination 130. Night sweats 131. Increased thirst 132. Lowered resistance to wound infection 133. Leg sores 134. Poor wound healing 135. Feel energized from exercise 136. Failing eyesight
4 137. Crave sweets, but eating sweets does not relieve symptoms 138. Family history of diabetes 139. Glucose (sugar in urine) 140. Elevated blood glucose (sugar) 141. Toe and fingernail fungus 142. History of antibiotic use 143. Anemic or recent history of anemia 144. Itchy skin 145. Itchy between toes and fingers 146. Abdominal bloating 147. Intestinal gas 148. Chemical sensitivities 149. Depression 150. Crave sweets and yeast containing foods 151. Bladder and kidney infections 152. Dark colored stool 153. Do not eat high fiber foods daily 154. Less than 7 bowel movements per week 155. More than 2 bowel movements per day 156. Bowel movements are irregular 157. Abdominal pain on right or left side 158. Abdominal pain relieved by a bowel movement 159. Abdominal pain is triggered by eating 160. Yellowish conjunctiva (white part of the eyes) 161. Pain radiates along outside of leg 162. Intolerance to greasy foods 163. Headaches after eating 164. Dark urine 165. Light colored stool 166. Hard stool 167. Gray colored skin 168. Pain in right side under rib cage 169. Big toe painful 170. Don't eat regular balanced meals 171. Don't get enough to eat 172. More than 10 beers/ week 173. More than 10 ounces of alcohol/week 174. Eat candy 175. Drink soda pop 176. Eat at fast food restaurants 177. Eat fried foods 178. Use refined sugars 179. Diet often 180. Hair loss 181. Dry skin 182. Bones protrude Don't use vitamins and minerals 184. Use very large-doses of vitamins and/or minerals 185. Neurological disorders 186. Sore or burning tongue 187. Lower back pains 188. Poor night vision 189. Confusion 190. Sore or sensitive gums 191. Leg pain or cramps 192. Pain in feet 193. Some alcohol use 194. High stress levels effect stomach 195. Lack of appetite 196. Dizziness 197. Inflamed corners of the mouth 198. Steeply curved nails 199. Exposed to lead in the air or water 200. Sensitivity to light 201. Sensitive to the cold 202. Weight gain 203. Change in personality 204. Loss of temper or irritable 205. Enlarged neck 206. Trouble waking up in the morning
5 207. Low sex drive 208. Swollen (bulging eyes) 209. Warm, moist skin 210. Tremors 211. Increased activity 212. Increased appetite 213. Weight loss 214. Insomnia 215. Diffuse tanning on exposed and unexposed portions of the body 216. Black freckles over the forehead, face, neck, and shoulders 217. Mood swings 218. Dark circles under the eyes 219. Slender fingers and extremities 220. Purple streak or line on the abdomen 221. Kidney stones 222. Osteoporosis 223. Emotional disturbances 224. Simultaneous inflammation in multiple joints 225. Simultaneous pain in multiple joints 226. Stiffness lasting more than 30 minutes on arising in mornings 227. Stiffness lasting more than 30 minutes after prolonged activity 228. Deformation of joints 229. Joints lock with movement 230. Early afternoon sleepiness 231. Skin nodules 232. Deep aching pain in bones, particularly the back 233. Pain increases when weight is applied 234. Vertebrae crush fractures 235. Bone fractures 236. Bones fracture easily 237. Pain in the extremities 238. Burning sensation in the extremities 239. Weakness in the extremities 240. Frequent tooth decay 242. Throbbing pain on one side or front and rear of head 318 Pain on one side or front and rear of head 319 Pain in the forehead only 243. Headache preceded by a short period of depression, irritability, or restlessness 244. Headache preceded by visual flashing zig-zag lines 245. Headache preceded by other visual disturbances 246. Visual disturbances disappear shortly after begins Nausea associated with 248. Sensitive to light, especially during 249. Sensitive to noise, especially during 250. Extremities are cold before and during 251. Family history of migraine 252. Difficulty with speech before 253. Intensity of increases when lying down 254. Often prefer seclusion 255. Frequent urinary infections 256. Rarely need to urinate 257. Urinate when you cough or sneeze 258. Painful or burning urination 259. Difficult urination s 260. Dripping after urination 261. Cannot hold urine 262. Rose colored (bloody urine 263. Cloudy urine 264. Strong smelling urine 265. Back or leg pains associated with dripping after urination 266. History of kidney or bladder infections
6 267. Back pain in the kidney area 268. General water retention 312. Drug / Medication addiction 313. Must repeat actions constantly 314. Making decisions is difficult 315. Constant flow of speech 316. Obsessed fear of danger 317. Previously Diagnosed Diabetic Type Previously Diagnosed Diabetic Type Previously Diagnosed Diabetic Type Previously Diagnosed Migraine 322. Previously Diagnosed Hypothyroidism 320. Previously Diagnosed with high Cholesterol 324. I m an Athlete For Males Only: 269. A sense of bladder fullness 270. Increased straining with smaller and smaller amounts of urine 271. Wake up at night to urinate 272. Pain or fatigue in the legs or back 273. Ejaculation causes pain 274. Difficulty attaining and/or maintaining an erection 275. Premature ejaculation 276. Pain/coldness in genital area 277. Infertile 278. Varicose veins on scrotum 279. Low sperm count 280. History of venereal disease For Females Only: 281. Vaginal yeast infections 282. History of oral birth control 283. Heavy menstrual flow 284. Prolonged 285. Short 286. Menstrual irregularities 287. Monthly weight gain 288. Moodiness and irritability before 289. Change in appetite before 290. Suicidal feeling before 291. Anxiety or anger before 292. Breast fullness and pain before 293. Leg cramps and tenderness before 294. Asthma attacks before 295. Bruise easily before 296. Respiratory allergies worsen before 297. Visual disturbances worsen before 298. Dull ache radiating to low back or legs 299. Abdominal pains subsides after several days 300. Pelvic soreness 301. Have to lie down on first or second days of period 302. Clots are expelled during 303. Hot flashes 305. Hysterectomy or Menopause 306. Heavy bleeding two weeks/month 307. Sweating throughout the day 308. Dryness of skin, hair, and vagina 309. Painful intercourse 310. Vaginal pain 311. Vaginal itching 6
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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
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
SYSTEMS SURVEY FORM. Doctor
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Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
Name Social Security Number Address: Street: _ New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification Date of Birth Gender: Male Female City: State Zip Code E-mail: Home Phone:
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
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
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Willow Naturals BioEnergetic Health Survey
Instructions: Indicate the symptoms which apply to you using the following scale (0) if "never" (1) if "rarely" ( 2) if "time to time" (3) if "often" Name: Date of Birth: Address: Phone Number: Email:
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland
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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
Placer Private Physicians: Patient Health Questionnaire [2]
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Name: Age: Gender: Name: Age: Gender: Name: Age: Gender:
Naltrexone Pellet Insertion Intake Form Name: Date of Birth: / / Contact Information: Phone: E-Mail: Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Why are
Health History Questionnaire Date: / /.
Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:
Candida Questionnaire: Are your health problems yeast connected?
Candida Questionnaire: Are your health problems yeast connected? The following questionnaire can be given to your clients if you suspect candida is a problem. YES NO Have you taken repeated courses of
SYSTEMS SURVEY FORM GROUP 1
SYSTEMS SURVEY FORM Patient Doctor Date Birth Date / / Approx Weight Vegetarian Gluten-free INSTRUCTIONS: Number only the boxes which apply to you. Leave blank if you don't have the problem. * Write 1
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Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX
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