Patient Intake Form. How did you hear about us? What are your major health concerns? 2. 3.
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1 Patient Intake Form Name: Address: City: State: Telephone: Hm Wk Date: Zip Date of Birth: Cell: Emergency Contact: Previous names used: Sex: Male Female Employer: Occupation: Education: (indicate highest level completed) grade high some college grad grad school school college grad school degree Marital status: (check one) single married partnered widowed separated divorced Living with: (check one) alone spouse partner family roommate(s) other How did you hear about us? What are your major health concerns? Was your PRIMARY problem diagnosed by a physician? yes no How long have you had the primary problem? What treatments have you tried for your primary problem? Are you taking any medications for your primary problem? yes no Are you taking any other medications? yes no Are you taking any vitamins or other supplements? yes no If yes, please list: Do you have any allergies to medications or substances? yes no 1
2 Circle the answer that best reflects the frequency of each symptom 0 = never 1 = seldom 2 = occasional 3 = often CONSTITUTION Part A: GENERAL 1. Height 2. Weight lbs 3. Frequent illness Dizziness Part B: SLEEP 1. Insomnia Restless legs when laying down Using a sleep aid? No Yes EYES 1. Watery / itchy eyes Dry / reddened eyes Blurred, tunnel, double vision Eye pain / fatigue EARS, NOSE, MOUTH, THROAT 1. Itchy ears Frequent pain / infections Ringing / hearing loss Stuffy nose / sinus problems Hoarseness, loss of voice Canker sores CARDIOVASCULAR SYSTEM 1. Chest pain/left arm pain/numbness Shortness of breath during minor activity Pain in shoulder or jaw (circle which) Swelling of feet and ankles Blood pressure higher than 120/80? No Yes RESPIRATORY SYSTEM 1. Difficulty breathing / asthma Chest tightness / pain / congestion Recurring/chronic cough DIGESTIVE SYSTEM Part A: GENERAL DIGESTIVE SYSTEM 1. Nausea/vomiting Recent change in appetite Blood in stool Bowel movements how often? /day Part B: DIGESTION Part B-1: DIGESTION: LOW ACIDITY 1. Indigestion Constipation Belching / burping / Food sits in stomach, undigested Undigested food in stools Do you have food sensitivities? No Yes Part B-2: DIGESTION: HIGH ACIDITY 1. Stomach pains 1-4 hours after meals Stomach pain relieved by milk/cream Heartburn lying down or bending fwd Constant need for antacids Ulcer? No Yes PART C: ASSIMILATION Part C-1: SMALL INTESTINE 1. Abdominal cramps, pain, bloating, gas Soft, pasty or unformed stool Fiber rich diet causes constipation Mucus in stool, greasy stool Stools have foul odor Frequent urination Increased thirst and appetite Part C-2: LARGE INTESTINE (COLON) 1. Diarrhea / constipation (circle) Frequent abdominal cramps Fingernail/toenail fungus/vag yeast infx Coated or fuzzy tongue Flatulence (gas) Use of antibiotics in the past year? No Yes PART D: LIVER / GALLBLADDER 1. Abdominal pain after eating fatty food Painful or tender big toe Hard, dry stool Stool color is gray or light Skin itches Headaches following meals Dry or flaky skin or hair Yellow sclera (white of the eyes) Bad breath or body odor Impatient, irritated, easy to anger Red or dry eyes Have had jaundice or hepatitis? No Yes 14 High cholesterol and/or low HDL? No Yes URINARY SYSTEM 1. Pain on urination Frequent urination Constant feeling of a full bladder Loss of control holding urine Drip/dribble after urination Straining to urinate with scant passage Awaken during night to urinate History of bladder infection/cystitis? No Yes MUSCULOSKELETAL Part A: BONE INTEGRITY 1. Pain in joints Gingivitis/gum sensitivity No Yes 3. Osteopenia/Osteoporosis? No Yes 4. Bone fracture in past two years? No Yes Part B: MUSCLE 1. Frequent muscle cramps / spasms Stiff upon awakening / after sitting Feeling of weakness / tiredness Fibromyalgia? No Yes Part C: CONNECTIVE TISSUE 1. Injured tendons / ligaments Lax ligaments / joint instability Tendonitis / bursitis Slipped / herniated disc? No Yes 2
3 SKIN 1. Acne / boils (circle) Hives / rash / dry skin (circle) Color change Lumps / bumps / outbreaks Unexplained broken capillaries/bruising NERVOUS SYSTEM 1. Numbness / tingling Diminished ability to feel calm, relaxed Convulsions / seizures Poor memory / concentration Imbalance of up and down moods Paralysis / loss of motor control No Yes ENDOCRINE Part A: ADRENAL 1. Cannot stay asleep Crave salt Energy low in morning to mid-afternoon Dizzy / light headed upon standing Catch colds or get sick easily Weak nails Perspire easily/ warm episodes Eyes sensitive to bright/direct light Past use of cortisone, prednisone PART B: THYROID Part B-1: Hypothyroid 1. Hands and feet are cold Constantly tired / fatigued Lack of stamina / motivation Skin is dry Especially tired in the later part of day Constipation Outer third of eyebrow thins Morning headaches that wear off Gain wt easily in spite of little food No Yes Part B-2: Hyperthyroid 1. Heart palpitations Increased pulse even at rest Insomnia Night sweats Eyes appear to bulge or be swollen Difficulty gaining weight Part C: PANCREAS: Part C-1 LOW BLOOD SUGAR 1. Strong desire for sweets and fats Sweets / alcohol relieve headaches fast Irritable if a meal is missed or late Frequently drowsy, impatient, moody Need caffeine to get going Hungry 1-3 hours after eating Feel shaky, weak or fatigued Feel better / calmer after eating? No Yes Part C-2 INSULIN RESISTANCE 1. Increased thirst & appetite Eating sweets does not alleviate cravings Must have sweets after meals Waist girth equal or greater than hip Fatigue after meals Family history of diabetes? No Yes 7. Difficulty losing weight No Yes LYMPHATIC/BLOOD 1. Need to clear throat, especially in AM Swelling in throat / neck Skin irritation / rash Nodules or tenderness in breasts Swelling in feet or ankles upon waking Puffiness beneath eyes in the morning IMMUNE SYSTEM Part A: LOW-FUNCTIONING 1. Runny nose Nose bleeds for no apparent cause Frequent chest and throat infections Lymph glands swell Ear infection/congestion Slow recovery from cold or flu Part B-1: HYPER-REACTIVE/CYTOKINE STORM 1. Food sensitivity / allergy Swallowing tablets is difficult Migraine headaches Low grade fever from time to time Achy flu-like feeling Bed wetting Attention deficit, hyperactivity FEMALE Part A: FEMALE, GENERAL 1. Sexual difficulties Pain during intercourse Sexually transmitted disease Vaginal itching / discharge Do you use birth control? No Yes Part B: SYMPTOMS DURING MENSTRUATION 1. Monthly weight gain Premenstrual breast pain or discomfort Moodiness / irritability / anger Bloating / swelling Nausea / vomiting (circle which) Monthly headaches tracking cycle Suicidal feelings? No Yes Part C: PAINFUL MENSTRUATION 1. Bleeding between periods Irregular cycles Muscle cramps / pain during cycles Heavy menstrual bleeding Must lie down first days of period Part E: HORMONAL BALANCE 1. Hot, sweaty flashes / flushes Night sweats Mood swings / depression Insomnia / light sleep Heavy, extended bleeding Vaginal dryness Low or no desire for sex (libido)? No Yes 3
4 MALE 1. Fatigue in legs or lower back Pain or discomfort upon ejaculation Sexually transmitted disease? No Yes 5. Testicular masses, pain? No Yes 6. Sexual difficulties? Decreased libido / sex drive LIFESTYLE: A = Always U = Usually O = Often S = Sometimes N = Never 1. Eat 3 meals a day? A U S N 2. Do you exercise? O S N How often? times/week What forms? 3. Do you drink coffee? O S N How much? cups/day 4. Do you drink black tea? O S N How much? cups/day 5. Do you drink soda? O S N How much? cans/day 6. Do you use recreational drugs? O S N How often? times/week 7. Do you use tobacco now? O S N What forms? How much? amount/number/day 8. Did you use tobacco in the past? O S N What forms? How much? amount/number/day How long? When stopped? Mo/ Yr Please list hospitalizations or surgeries that you have had - What immunizations have you had? Check = immunization received.? = do not know. Polio Pertussis Tetanus shot (not antitoxin) Diptheria Measles/Mumps/Rubella Other: 4
5 SELF AND FAMILY HISTORY Please indicate if a member of your family has had the following conditions by checking the appropriate boxes: Father Mother Brothers Sisters Grandfathers Grandmothers Allergies Asthma Cancer Diabetes Gallbladder Disease Heart Disease High Blood Pressure Kidney Disease Kidney Stone(s) Mental Illness Osteoporosis Stroke Please indicate if you have ever had the following conditions by checking either yes or no: Condition YES NO Condition YES NO Condition YES NO Anemia Glaucoma Mental illness Arthritis Asthma Cancer Cataracts Diabetes Emphysema Epilepsy Gallbladder disease Head injury Heart disease Hemorrhoids High blood pressure Hypothyroid Kidney disease Kidney stone(s) Learning disability Osteopenia/porosis Pneumonia Rheumatic fever Stroke Thrombophlebitis Tuberculosis Ulcer Vericose veins 5
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1835 W. County Rd C, Suite 80, Roseville, MN 55113 P: 651-797-6880 F: 651-797-6881 info@spartzvein.com spartzvein.com Medical Information Date of consultation: (office use) MRN: CMRN: Last Name: First
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Metabolic Assessment Form
Metabolic Assessment Form Name: Age: Sex: Date: PART I Please list the 5 major health concerns in your order of importance:... 4. 5. PART II Please circle the appropriate number - on all questions below.
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
55 S. Main Street, Driggs, ID (208)
Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F
New Patient Medical History Form
New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring
Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
PATIENT QUESTIONNAIRE / ASSESSMENT
PATIENT QUESTIONNAIRE / ASSESSMENT Diabetes Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital Status:
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No
ADULT HEALTH HISTORY Name Date Address City State Zip code Phone, please circle your preferred number: (home) (cell) (work) E-mail Yes No (if you would like email appointment reminders) May we email you
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
Patient Information & Health History
Patient Information & Health History Name Date Date of Birth (mm/dd/yy) Age Male Female Address City Postal Code Occupation Phone (H) E-mail Phone (C) Married Single Divorced Widowed Phone (W) Spouse s
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies: