Consultation Intake Form. Name: Age: Sex: M F T Address: Phone: (day) (evening) Birth date: Present physical complaints:

Transcription

1 Consultation Intake Form Date: Name: Age: Sex: M F T Address: Phone: (day) (evening) Birth date: What would you like help with at this time? Present physical complaints: Onset and length of symptoms: At or around the time of onset were other emotional or physical stresses occurring? List any medications you are presently taking: List any Herbal Medicines, Supplements, Homeopathics, and Over the Counter Medications you are presently taking: Medication/Herb/Etc. Reason for Use Dosage Times a day Please bring all vitamins, herbs, supplements, over the counter and prescription medications with you to your appointment.

2 PAST MEDICAL HISTORY: Surgical History: Other Hospitalizations: Serious accidents, falls or injuries: Any childhood accidents or physical traumas? Do You Have Any Allergies? To What? Present Weight: One Year Ago: 5 Years Ago: GENERAL: Do you have or have you had any of the following? High Blood Pressure Acne Anorexia/Bulemia High cholesterol Eczema Hepatitis Diabetes Heart Problems Skin Rashes Headaches Urinary tract infection Skin Fungus Asthma Kidney Problems Fatigue Sinus Problem Fainting Spells Swollen Lymph Lung problems Frequent Cold or Flu Cancer Emotional Issues Wounds heal slowly Tried but can t loose weight How do you usually get sick or experience bodily distress? (digestive, respiratory, reproductive etc.) How often does this happen? FAMILY HISTORY: (List any medical conditions, problems in family members) LIFESTYLE: Tobacco Use: Yes No Past How Much and How Often: Alcohol Use: Yes No Past How Much and How Often: Caffeine Use: Yes No Past How Much and How Often: Other Drug Use: Yes No Past How Much and How Often:

3 How frequently do you exercise? Daily Weekly Rarely Type of exercise: DIET: Breakfast: Lunch: Dinner: How many meals a week do you dine out? How many times a week do you have: Beef White Rice Soda Pop Pork White Bread Coffee Fish Crackers Black Tea Chicken Chips Milk Desserts Ice Cream Other Dairy Canned Foods What would you say is the worst thing that you do on your diet? Are you subject to binge eating? Of what foods? What food do you find to be your weakness? Do you eat breakfast every day? Eat regular meals? DIGESTION: Appetite: good fair poor Digestion: good fair poor Do you experience Bloating or Gas after meals? Sour burps or heartburn? Do you feel Sleepy or Tired after meals? How often? Daily /Weekly /Occasional Are you on a Restricted Diet? Explain: When is the last time you took antibiotics? Do you feel agitated or low functioning if you don t eat regularly? ELIMINATION: How often do you have a bowel movement? Daily Times per Week Irregular Do you ever have hard stools? Do you ever have loose stools? Urination: normal scanty more than 5 times daily burning strong odor dark color How many glasses of water do you drink daily? Any history of bladder or kidney infections? If so, at what age? WOMEN S HEALTH: Do you experience any of the following, past or present? PLEASE CIRCLE Breast pain Irregular PAP Difficulty getting pregnant Endometriosis STD s including HPV Fibroids Vaginal dryness Ovarian cysts Vaginal infection Irregular menstrual cycles Hot flashes Difficult menopause Pelvic pain Currently pregnant No menstruation

4 MENSTRUAL CYCLE INFORMATION: How many days do you menstruate? Spotting before or after period: Clots? Yes no Clot Size Number of clots Color of menstrual blood: bright red maroon brown Volume of menstrual blood MEN S HEALTH: Frequent Urination Reproductive Issues Prostate Problems Painful Urination Anything else? STRESS LEVEL: What would you rate your level of stress (0= no stress, 10 = maximum stress) What are the major sources of stress in your life? Who provides you support in your life? How many hours of sleep do you get on an average night? Insomnia? Do you usually wake up feeling tired or rested? Nerves: good fair poor Anxiousness: often sometimes seldom Depression: often sometimes seldom Please explain your responses: EMOTIONAL AND SPIRITUAL: If romantically involved, how is your relationship? Were there any emotional traumas in your early or present life? Please explain briefly. (ie. rape, great loss, suicide or death of a loved one, etc.) If possible, please explain what you feel to be your most experienced negative emotion: When do you most often feel this emotion? Where are you, when you feel this negative emotion? What is your opinion of yourself? Have you ever been to counseling? What was the outcome for you? Briefly explain your relationship with each of your parents? Mom: Dad:

5 Rate Yourself: None Some Lots Faith Hope Charity Generosity Humor Fun WORK AND RECREATIONAL ACTIVITIES: Occupation: Do you enjoy your work? Are you involved with activities outside of work? If so, what type of activities? Do you have any hobbies or interests? Is there an unrealized longing in your life? What is it?