ANDREWS HEALING ARTS CLINIC 20Dunk Rock Road #2, Guilford, CT Patient Intake Form
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- Oliver Patrick
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1 Patient Intake Form 1 Date: Dr.: Patient Name: List your health concerns in order of importance: 1) 2) 3) 4) 5) Name and telephone number of Primary Care physician: Family History Father Mother Siblings Grandparents Spouse Children Age if living: Age when died: Reason for death: Cancer type: High Blood Pressure: Y N Y N Y N Y N Y N Y N Heart Attack/Stroke: Y N Y N Y N Y N Y N Y N Heart Disease: Y N Y N Y N Y N Y N Y N Asthma/Allergies: Y N Y N Y N Y N Y N Y N Mental Illness: Y N Y N Y N Y N Y N Y N TB: Y N Y N Y N Y N Y N Y N Auto-Immune Disease: Y N Y N Y N Y N Y N Y N Diabetes Mellitus: Y N Y N Y N Y N Y N Y N Osteoporosis: Y N Y N Y N Y N Y N Y N List All Surgeries & Hospitalizations, including date occurred: 1) 4) 2) 5) 3) 6)
2 2 Please Note When & Why You Have Had Each of the Following: X-Rays: MRI/Cat Scans: Ultrasounds: Accidents: TB Test: HCV: HIV: Last Dental Visit: Last Eye Exam: Did you have the following Disease (D), Get Immunized (I), or Neither (N): Measles: D I N Chicken Pox: D I N Hemophilus (Hib): D I N Rubella: D I N Tetanus: D I N Whooping Cough: D I N Mumps: D I N Hepatitis B: D I N Any vaccination reactions: List Yes (Y), No (N) or Past (P) regarding use of the following: Antacids: Steroids: Smoking: Packs per day & number of years: Analgesics: Laxatives: Coffee: Cups per day if Yes/Past: Soda Pop: Ounces per day if Yes/Past: Alcohol: How often & how much if Yes/Past: Any Alcohol Addiction: Any Alcohol Treatment: Recreational Drugs: Any Drug Addictions: Any Drug Treatment: List all Prescription Medicines & Nutrient Supplement/Herbs that you are taking and including dosage: Review of Systems: Present Weight: Weight one year ago: Height: Maximum weight and when: Minimum weight as adult & when: Ideal Weight: REGARDING THE NEXT LONG SECTION: Please circle (Y) if you have the problem NOW, (N) if you ve NEVER had the problem, (P) if you had the problem in the PAST. Good Energy: Fatigue: If you have fatigue, when in morning, afternoon, evening is it the worst? If you have fatigue, can you do what you need to during the day? Y N
3 3 SKIN Rash: Color Change: Hives: Lump: Psoriasis/eczema: Itchy: Dry: Warts/moles: Cancer: Perspiration: HEAD Headache: Migraine: Dandruff: Head Injury: Oil/dry hair: Hair loss: NOSE Frequent Colds: Nosebleeds: Congestion: Post Nasal Drip: Polyps: Seasonal Allergies: EYES Dry/Watery: Blurry Vision: Double Vision Cataracts: Glaucoma: Styes: Strain: Discharge: Itchy: Dark under Eyelid: MOUTH/THROAT Canker sores: Cold sores: Sore Throat: Gum disease: Dentures: Cavities: Loss of taste: Hoarseness: NECK Stiffness: Swollen Glands: Full movement: Tension:
4 4 RESPIRATORY Cough: TB: Shortness of breath w/ exertion: Bronchitis: Shortness of breath sitting: Pneumonia: Shortness of breath lying down: Asthma: Wheezing: Painful breathing: CARDIOVASCULAR High Blood Pressure: Rheumatic Fever: Low Blood Pressure Murmurs: Arrhythmias: Palpitations: Edema: Chest Pain: URINARY TRACT Incontinence: Pain w/ Urination Frequent Infections: Kidney Stones Urgency: Discharge/Blood: GASTROINTESTINAL Heartburn: Bowel Movement Freq: Indigestion: Recent BM Change: Bloating: Diarrhea/Constipation: Nausea: Hemorrhoids: Vomiting: Gall Bladder Disease Change in Appetite: Liver Disease: Pancreatitis: Ulcer MALE Testicular pain/swelling: Sexually Active: Hernia: S.T.D.: Discharge: Prostate Disease/Symptoms: Impotency: Sexual Orientation
5 5 FEMALE Age Period Began: How Often Period Occurs: How long period lasts: Heavy menstrual bleeding: Menstrual cramping: Menstrual Pain: PMS: Food cravings: Times Pregnant: How many births: Miscarriages: Abortions: Last Pap Smear: Sexual Orientation: Any abnormal paps: When was abnormal: Menopausal since what age: Use of hormones: Type of hormones used: Healthy libido: Dry vagina: Sexually Active: Pain w/ Intercourse: Vaginitis: S.T.D.: Mammography: Bone Density Test: If Yes, what were results: Please list any birth control used and ages used: MUSCULOSKELETAL Weakness: Arthritis: Stiffness: Leg Cramps: Tremors: Pain: NERVOUS Paralysis: Sciatica: Tingling/numbness: Carpal tunnel syndrome: Seizures: Fainting: Mental/Emotional Depression: Anger/irritability: Suicidal: High-strung/tense: Anxiety: Fear/Panic Eating disorder: Psych Hospitalization:
6 6 Exercise How often do you exercise? What type of exercise? For how long? Hobbies: Sleep How long per night? If you wake up frequently, what is the reason? Nightmares: Wake Refreshed: Must nap during the day: Sleep walk: Grind teeth: Snore: Toxin Exposure Did you grow up near any refinery, polluted area or in a home with leaded paint? If so, what sort of pollution were you exposed to? Have you had any jobs where you were exposed to solvents, heavy metals, fumes or other toxic materials? Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing? Are you particularly sensitive to perfumes, gasoline or other vapors? Do you use pesticides, herbicides or other chemicals around your home? Social Life Enjoy job: Hours worked per week: Highest Level of Education: Active spiritual practice: Quality of significant relationship: History of sexual, mental/emotional, physical abuse: What is your greatest health concern: How does it limit you the most: How committed are you towards making valuable changes: Little Moderately Very Diet: Please provide sample daily diet for breakfast, lunch dinner and snacks.
7 Allergies List all known Allergies (food, drugs, environment): 7 Additional Information Please list any additional information/topics which you believe is important we address during your office visit:
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PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: SS#: - - Address: City, State, Zip Code Single( ) Married( ) Partner( ) Divorced( ) Widowed( ) Legally Separated( ) Male( ) Female(
Signature: Today s date: (Parent or Guardian if a minor)
487 Davie St. Vancouver, V6B 2G2 Ph:604-697-0397/ Fax:604-697-0883 PERSONAL INFORMATION Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship
S u n s h i n e. Health Care Center N 94th Drive, Ste. C-4 Peoria, AZ ADULT INTAKE FORM
ph (623) 266-1722 fax (623) 266-1746 13660 N 94th Drive, Ste. C-4 Peoria, AZ 85381-4841 www.sunshinehealth.net info@sunshinehealth.net ADULT INTAKE FORM Name: Date: Date of birth: Age: Gender: Address:
Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:
Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship
Date of Birth Work Phone # ( ) Home Phone # ( ) Emergency Contact # ( )
Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. It should take 15-20 minutes. Contact Information: Name Occupation
Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
MEDICAL HISTORY RECORD
MEDICAL HISTORY RECORD Please print and complete all information. Case. Male Female Medicare. Medicaid. Today s Date Birthdate Last Name First Middle Daytime Phone Home Phone Address City Marital Status
Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History
Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History Name: Date: PRESENT HEALTH CONCERNS: Please list your most important health concerns in order of their
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a