Client Intake Form. Today s Date: / / (mm/dd/yyyy) Name. Birthdate: / / (mm/dd/yyyy) MEDICAL TEAM Family physician: Specialty (if applicable)

Transcription

1 Client Intake Form Today s Date: / / (mm/dd/yyyy) Name: Birthdate: / / (mm/dd/yyyy) MEDICAL TEAM Family physician: Name Specialty (if applicable) City State Zip Oncologist: Name Specialty (if applicable) City State Zip Other (surgeon, naturopath, chiropractor) Name Specialty (if applicable) City State Zip Pharmacy Information: Pharmacy Name City State Zip Fax Page 1 7

2 CANCER DIAGNOSIS Stage and Type of Cancer Metastasis (y/n) Treatments Surgery No Yes (what kind?) Chemapy No Yes (what agents?) Radiation No Yes (to where?) Hormonal Therapy No Yes (what?) Other No Yes (what?) Surgery No Yes (what kind?) Chemapy No Yes (what agents?) Radiation No Yes (to where?) Hormonal Therapy No Yes (what?) Other No Yes (what?) Have most recent blood test results been obtained? Yes No Has most recent radiologic report been obtained, if applicable? Yes No Has most recent pathology report been obtained, if applicable? Yes No If yes for any of the above, please submit with this intake form. Page 2 7

3 OTHER DIAGNOSIS Besides cancer, what conditions have you been diagnosed with? SYSTEMS Please circle any symptoms that you currently feel. Category Issues No problems General appetite change fatigue fever sweats weight loss weight gain weakness Skin itching rash psoriasis eczema mole change(s) Eyes vision change cataracts glaucoma Ears/nose/mouth dizziness ringing in ears hoarseness sore throat runny nose nosebleeds Lungs cough shortness of breath chest pain coughing blood weeping Heart chest pain palpitations fainting episodes leg pains Gastro-intestinal / Digestive heart disease abdominal pain nausea vomiting diarrhea gas constipation jaundice black stools bloody stools difficulty swallowing hemorrhoids leaky gut food allergies/sensitivities IBS/Crohn s or ulcerative Colitis Genitourinary painful urination increased frequency urgency blood in urine kidney stones urinating at night Musculoskeletal arthritis stiffness swelling weakness backache Page 3 7

4 Nervous system headache seizures dizziness tremors memory loss paralysis numbness/tingling anxiety depression personality change suicidal thoughts Male reproductive infertility testicular pain swelling sexual dysfunction Female reproductive infertility pelvic pain loss of period abnormal bleeding sexual dysfunction Hematologic bruising bleeding recurrent infections Lymph nodes enlargement tenderness Metabolic / no energy hypo/er-thyroidism adrenal insufficiency endocrine hormonal imbalances osteoporosis diabetes Immune System rheumatoid arthritis lupus Hashimotos Graves multiple sclerosis Check all issues that apply or answer questions in the space provided: Blood Sugar Diabetes Pre-diabetic Hypo/er-glycemic Experience irritability or shakiness when hungry Dental Health Mercury fillings Root canal(s) Bleeding gums Other dental issue: Adrenals Stress level 1-10 (10 highest): 3 biggest sources of stress (pre-diagnosis): biggest sources of stress (post-diagnosis): Sleep patterns Usual bed time: Usual wake up time: # hrs sleep per night (avg.): # sleep disturbances / night (avg.): Dreams/nightmares Page 4 7

5 Pain Experience Pain? If so: Location(s): Frequency: Duration: Severity: Etiology (causes): Career/ Contribution Occupation: Full or Part time: Sick time frequency: Vacation days per year taken: Emotional Health Check those that apply and rate how feel on a scale of 1 to 10 (10 being most severe): Sad: Depressed: Lonely: Anxious: Grief: Fearful: Lack of control: Responsible for your illness: Resilient (i.e. ability to bounce back ): Spiritual Health Attend church/temple or place of worship Pray Believe in a higher spiritual force/being/ universal energy Practice gratitude Spend time in nature Spend time being present and observing Laugh often Wonder Be present and give attention Finances and Health Insurance Undergoing financial hardship Carry health insurance, Medicare, or Medicaid Carry disability insurance Physical Health List forms of exercise/movement: How often do you exercise? Do you have any physical limitations? If so, list: Page 5 7

6 Stress Management and Meditation How do you manage stress? Check any that you do regularly or add ways that you de-stress: Meditation Deep breathing Visualization Yoga Qi Gong Reading Add : Organization Your house contains clutter Your kitchen cabinets and refrigerator may contain old/expired items You keep medical records and bills/receipts You have an appointment book and contacts You have important legal documents in place (e.g. will, power of attorney) You have a list of your prescription medications HOME/ PERSONAL CARE/ ENVIRONMENT Please check all that apply to you and answer any additional questions: The air where I live is relatively clean. I use common household cleaning products? What brands do you typically use? I use cosmetics. What kind/brands? I am exposed to chemicals in my home or work environment. If so, explain: I have environmental allergies (e.g. pollen, dust, mold ). If so, what: I use plastic containers/cups I use a computer for more than 2 hours a day on average I sleep near electronics DIET/FOOD/WATER Please check all that apply to you: I eat processed food If so, what is the % of foods you eat that is processed vs. whole: I cook If so, what is the % of times you cook vs. eat out or have prepared food: I eat only organically grown fruits and vegetables I eat animal products (meat, eggs, cheese, poultry, fish, etc.) I have a garden or grow herbs or sprouts Page 6 7

7 I know what whole food means I have/ eat(en) fermented foods (e.g. sauerkraut, kimchi, kefir, kombucha) I have had bone broth I live near a farm or have farm stands in my area that I go to I drink tap water I drink filtered water (or type of water that processes out chemicals) I drink spring water Page 7 7