Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
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1 Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Address: Date of Birth: Marital Status: Married Separated Divorced Widowed Single # Children Live with: Spouse Partner Parents Children Friends Alone: Occupation: Hours per week: Retired: Employer: Work Address: How did you hear about The Riordan Clinic and/or who can we thank for referring you? Emergency Contact: Address: Relationship: Phone: What are your most important health problems? List in order of importance Are you hypersensitive to: Any drugs? Any foods? Any substances in the environment or chemicals? Allergies RC NPIntakeForm Page 1 of 7
2 Family History Age if living: Age when Died: Reason for Death: If Cancer, type: Father Mother Siblings Maternal Grandparents Paternal Grandparents Spouse Children Thyroid Disorder High Blood Pressure Heart Attack Asthma / Allergies Mental Illness Autoimmune Diabetes Osteoporosis Other If present, mark an X Current Medications/Supplements Please list any prescription, over the counter medications, or vitamins/supplements you are taking and dosages: OTC Medications Prescription Medications (ibuprofen, antacids, sleep aids, laxatives, etc.) Vitamins/Supplements Page 2 of 7
3 Health Assessment General Information (Y) = Yes (N) = No (P) = in the Past Current Height: Weight: Weight 1 Year Ago: Maximum Weight: When: Ideal Weight: Do you have sufficient energy throughout the day? Y N Please rate your energy from 1-10 (best)? When is your energy best? When is your energy worst? Habits/Lifestyle (Y) = Yes (N) = No (P) = in the Past Main interests and hobbies: Do you exercise? Y N If yes, what kind/how often Hours of sleep each night Enjoy your work? Y N Sleep well? Y N Take vacations? Y N Awake rested? Y N Spend time outside? Y N Have a supportive relationship? Y N How many hours of TV per day? Have a history of abuse? Y N How much time/day in relaxation? Been treated for drug dependence? Y N Do you eat 3 meals a day? Y N Use Alcoholic beverages? Y N Do you go on diets often? Y N Treated for alcoholism? Do you eat out often? Y N Do you use tobacco? Do you drink coffee? How many years and packs/day? Do you drink soda/pop? Y N Have a religious/spiritual practice? If yes, quantity per day or week Page 3 of 7
4 REVIEW OF SYSTEMS (Y) = Yes (N) = No (P) = in the Past Mental / Emotional Treated for emotional problems Depression Mood Swings Anxiety or nervousness Considered/Attempted suicide Tension Poor concentration Memory problems Immune Reactions to immunizations Chronic infections Chronic Fatigue Slow wound healing Chronically swollen glands Endocrine (Hormone System) Underactive thyroid Heat or cold intolerance Low blood sugars Excessive hunger Excessive thirst Seasonal depression Fatigue Night Sweats Neurologic Seizures Paralysis Muscle weakness Numbness or tingling Loss of memory Loss of balance Vertigo or dizziness Motion Sickness Skin Rashes Eczema/Hives Acne Itching Color changes Hair loss Lumps Brittle Dry skin Page 4 of 7
5 Head/Neck Headaches Jaw/TMJ problems Migraines Lumps Head injury Swollen glands Eyes Spots in Eyes Cataracts Impaired vision Glasses/contacts Blurriness Eye pain/strain Color blindness Tearing or dryness Double vision Glaucoma Ears Impaired hearing Ringing in the ears Earaches Dizziness Nose and Sinuses Frequent colds Nose Bleeds Stuffiness Hay fever/post Nasal Drip Sinus problems Loss of smell Mouth and Throat Frequent sore throat Copious saliva Teeth grinding Sore tongue/lips Gum problems Hoarseness Dental cavities Respiratory Cough Pain on breathing Spitting up blood Shortness of breath Asthma Shortness of breath lying down Pneumonia Bronchitis Emphysema Page 5 of 7
6 Cardiovascular Heart disease Swelling in ankles High Blood pressure Chest pain Blood clots Murmurs Phlebitis Fainting Rheumatic fever Palpitations Gastrointestinal Trouble swallowing Heart burn/reflux Change in thirst Abdominal pain/cramps Change in appetite Belching or passing gas Nausea/vomiting Constipation Ulcer Diarrhea Yellow skin Bowel Movements per day Gall bladder disease Black stools Liver disease Blood in stool Hemorrhoids Urinary Pain on urination Increased frequency Frequency at night Inability to hold urine stream Frequent infections Kidney stones Musculoskeletal Joint pain or stiffness Arthritis Broken bones Weakness Muscle spasms/ cramps/ pain Sciatica Osteoporosis / Osteopenia Blood Vessels Easy bleeding or bruising Anemia Deep leg pain Cold hands/feet Varicose veins Page 6 of 7
7 Male Reproductive Hernias Prostate disease Testicular pain Discharge or sores Are you sexually active Sexually transmitted disease Impotence If yes, which one(s): Testicular masses Female Reproductive/Breasts Age of first menses Birth Control Age of last menses (if menopausal) What type: Length of cycle (days) Number of pregnancies Duration of menses (days) Number of live births Are cycles regular Number of miscarriages Bleeding between cycles Number of abortions Painful menses Endometriosis Heavy or excessive flow Ovarian cysts PMS Breast lumps If yes, what are your symptoms Nipple discharge Last pap smear Last mammogram Pain during intercourse Have you had a bone density scan Y N Page 7 of 7
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