Adult Intake Form. Full name: Address: Province: City: Postal Code: Telephone number: Home: ( ) -
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- Brett Wheeler
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1 Adult Intake Form Personal Information: Full name: Date of Birth / / Gender: Today s Date: / / Occupation: Address: Province: City: Postal Code: Telephone number: Home: ( ) - Work: ( ) - Mobile: ( ) - May we leave you phone messages/call to confirm and cancel appointments? Yes No Marital status: Single Married Separated Divorced Widowed Number of dependents: How did you hear about the clinic? Who were you referred by? Emergency Contact: Name: Relationship: Phone Number: ( ) - Other Health Care Providers: Name of family doctor: Phone: ( ) - Name of specialists/doctors: Phone: ( ) - Name of specialists/doctors: Phone: ( ) -
2 Last physical exam (MM/YY): Last Blood work: (MM/YY): Medical History: Please list you HEALTH CONCERNS/GOALS by the order of importance: Concern/Goal Since Please indicate any TRAUMATIC EVENT (surgery, trauma), illnesses, injuries and hospitalization along with approximate dates: Traumatic event Date Medications, Supplements and Allergies: Please list all your current MEDICATIONS/SUPPLEMENTS: (prescription, over the counter, Vitamins, minerals, herbs, homeopathics, etc Item Dose Frequency Taken For Date Started
3 In the last five years, how many courses of antibiotics have you taken: When was the most recent course of antibiotics: Please list any ALLERGIES or MEDIC ALERT warnings (food, drugs, herbs, environmental): 1. Reaction: 2. Reaction: 3. Reaction: 4 Reaction: 5. Reaction: Please answer the following as it best describe you currently (please include amount, type, frequency, and duration of use if applicable): Y/N Number Other Smoke Cigarettes per day: Have you smoked in the past? For How Long? Are you exposed to second hand smoke? Recreational Drugs How many per Week: Drink Water Glasses per day: Drink Coffee Cups per day: Drink Tea Cups per day: What type of tea? Drink Pop/Soda Cups per day: Drink Alcohol Glasses Per week: What Type of alcoholic beverage: Exercise Hours per week: Type of exercise: Work Hours per week: Occupation: Do you enjoy your job? Shift work? Watch TV Hours per day: Screen time Hours per day: (Computer/Cell) Antacids How often: Laxatives How often:
4 Stress On scale of 1-10 (1=low, 10=high) What is the main stressor in your life? (e.g. Financial, Job related, marriage, family, Health, unfulfilled expectations, etc) Energy On scale of 1-10 (1=low, 10=high) Sleep Hours per night: Is your sleep Solid or interrupted? Do you wake up refreshed in the morning? Review of Systems Y: A conditions you have now P: A condition you have had in the past 1. SKIN Comments Rashes Y P Eczema, Hives Y P Acne/ Boils Y P Itching Y P Colour Changes Y P Lumps Y P Night Sweats Y P Dryness/Moisture Y P Temperature Y P Nail Changes Y P Change in mole Y P Skin Cancer Y P 2. HEAD Comments Headache Y P Head injury Y P Dizziness Y P Eye Pain Y P Tearing/Dryness Y P Double vision Y P Glaucoma Y P Cataracts Y P Blurring Y P Bothered by sun Y P Itching Y P Redness Y P Discharge Y P Blind spot Y P 4. EARS Comments Impaired hearing Y P Earache Y P Dizziness Y P Discharge Y P Infections Y P 3. EYES Comments Impaired Vision Y P Glasses/Contacts Y P 5. NOSE & IMMUNE SYSTEM Comments Frequent colds Y P Nose bleeds Y P
5 Stuffiness Y P Hay fever Y P Sinus problems Y P 6. MOUTH & THROATS Comments Frequent sore throat Y P Sore tongue/mouth Y P Gum Problems Y P Hoarseness Y P Dental Cavities Y P Loss of taste Y P 7. URINARY Comments Pain on Urination Y P Increased Frequency Y P Frequency at Night Y P Inability to Hold Urine Y P Frequent Infections Y P Kidney Stones Y P Blood in Urine Y P Urgency Y P Hesitancy Y P 8. RESPIRATORY Comments Cough Y P Sputum Y P Spitting up Blood Y P Asthma Y P Bronchitis Y P Pneumonia Y P Pleurisy Y P Emphysema Y P Wheezing Y P Difficulty Breathing Y P Pain on Breathing Y P Shortness of Y P Breath (SOB) SOB at night Y P SOB lying down Y P Tuberculosis Y P Tuberculin Test Y P Last chest X-Ray 9.NECK Lumps Y N Swollen Glands Y N Goiter Y N Pain or Stiffness Y N Comments 10. CARDIOVASCULAR Comments Heart disease Y P Angina Y P High blood pressure Y P Chest Pain Y P Murmurs Y P Swelling in Ankles Y P Palpitation/Fluttering Y P Cyanosis (Blue Y P lips/nails) Rheumatic Fever Y P Past ECG Y P Other: 11. GASTROINTESTINAL Comments Trouble swallowing Y P Nausea Y P Vomiting Y P Heartburn Y P Change in Thirst Y P Change in Appetite Y P Blood in Stool Y P
6 Belching or Passing Y P gas Vomiting blood Y P Jaundice (Yellow Y P skin) Liver Disease Y P Gallbladder Disease Y P Ulcer Y P Indigestion Y P Diarrhea Y P Rectal Bleeding Y P Hemorrhoids Y P Black, Tarry stool Y P Abdominal pain Y P Food Allergy Y P Hernias Y P 12. BREASTS Comments Lumps Y P Pain/Tenderness Y P Nipple Discharge Y P Do you self-exam Y P 13. MUSCULOSKELETAL Comments Arthritis Y P Joint Pain and Y P Stiffness Broken Bones Y P Weakness Y P Joint Swelling Y P Backache Y P Muscle Spasm/Cramp Y P 14. PERIPHERAL VASCULAR Comments Deep leg pain Y P Cold hands/feet Y P Varicose veins Y P Thrombophlebitis Y P Leg Cramps Y P Extremity numbness Y P Extremity Coldness Y P Extremity Swelling Y P Extremity Ulcers Y P 15. NEUROLOGICAL Comments Fainting Y P Seizures/ Convulsions Y P Paralysis Y P Muscle Weakness Y P Numbness/Tingling Y P Memory Loss Y P Involuntary Movement Y P Loss of Balance Y P Speech Problems Y P 16. ENDOCRINE Comments Heat/Cold Intolerance Y P Thyroid Trouble Y P Excessive Thirst Y P Excessive Hunger Y P Excessive Urination Y P Excessive Sweating Y P Diabetes Y P Hypoglycemia Y P Hormone Therapy Y P 17. BLOOD/ LYMPHATIC Comments Anemia Y P Easy Bleeding/Bruising Y P Lymph Nose Swelling Y P Past Transfusion Y P
7 18. MALE REPRODUCTIVE Comments Hernias Y P Testicular Masses Y P Testicular Pain Y P Sexual Difficulties Y P Venereal Disease Y P Discharge/Sores Y P Date of Last Prostate Exam 19. FEMALE REPRODUCTIVE Age Menses began Average Number of Days Length of Cycle Bleeding between periods Y P Are Cycles Regular Y P Pain During Intercourse Y P Painful Menses Y P Excessive Flow Y P PMS Y P EMOTIONAL Comments Depression Y P Mood swings Y P Anxiety/ Nervousness Y P Tension Y P Phobias Y P Alcohol/ Drug Abuse Y P Insomnia Y P Birth Control Y P What type? Number of Pregnancies Number of Live births Number of miscarriages Number of Abortions Difficulty Conceiving Y P Vaginal Discharge Y P Vaginal Itching Y P Are you Currently pregnant Y N Are you Breastfeeding? Y N Are you trying to conceive Y N Are you taking Birth Control Y N Pills Type: Date of Last Mammogram Date of last Pap Smear test Date of last bone density test Date of last menstrual period Family History: Asthma Cancer Type: Depression Anxiety Mother Father Gr. Parents Siblings Children
8 Mental Illness Diabetes Heart Disease High Blood Pressure High Cholesterol Kidney Disease Lung Disease Osteoporosis Thyroid Illness Substance Abuse Other Health Concerns Pain: Please mark the areas where you have pain: Past Medical History: Please check the following conditions you have had: Yes Never Comments Anemia Asthma Arthritis Cancer Type: Cold Sores Diabetes Heart Disease High Blood Pressure High Cholesterol
9 Anxiety Depression Other Mental Illness Thyroid Conditions Stroke Multiple Sclerosis Gout Kidney Disease Lung Disease Osteoporosis Thyroid Illness Substance Abuse Other Health Concerns Social History and Lifestyle: Dietary Intake: Please List a Typical day s diet including beverages: Breakfast: Lunch: Dinner: Snack: Beverages: Do you have any dietary Restrictions? (Allergy, religious, Vegetarian, vegan, etc): Do you have Any Pets? Yes No Have you ever been neglected or abused, Physically, emotionally or sexually? Yes No Are you currently living in an unsafe environment? Yes No Do you practice safe sex? (i.e. use condoms) Yes No Do you have more than one sexual partner? Yes No Sexual Partners: Men Women Both None Please describe the emotional climate of your home:
10 Health Maintenance: When was the last time you Date/ Findings Visited the dentist Had blood work Had a blood sugar test Had a Cholesterol test Had a Liver Panel test Had a Hormone Panel test Had tetanus booster Had EKG Had Chest X-Ray Had colon cancer screening: Type: Colonoscopy Flexible Sigmoidoscopy occult Blood stool test Note to all patients: Please bring in your medications and supplements to first appointment I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner s part should I fail to do so. Signature Date Thank you for taking the time to fill out this extensive health intake form. All the above information is important in developing the best treatment plan for you.
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