Southern Maine Integrative Health Center Adult Intake Form

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Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address: Emergency Contact: Relationship: Home Phone: ( ) Work Phone: ( ) Why have you come to the office today? Is this a new problem? Please describe your problem, including where it is, how severe it is, how long it has lasted. Medication Allergies: If any, please list allergy and type of reaction. Height: Personal Profile Weight: Marital status: married living with partner single widowed divorced Number of people in household: Current or most recent job: Travel outside of the u.s.? Current Medications (including hormones, vitamins, herbs, nonprescription and prescription medications) Drug name dosage Who prescribed Drug name dosage Who prescribed 1

Name: Gynecological History Physician s Notes Last normal menstrual period (first day): / / Age periods began: Length of periods (Number of days of bleeding): Number of days between periods: Any recent changes in periods? Are you currently sexually active? Present method of birth control: Have you ever used an intrauterine device (IUD) or birth control pills? If yes, for how long? When was your last pap test? What was the result? Have you ever had an abnormal pap test? Do you do regular breast self examinations? When was your last mammogram? What was the result? Any abnormal mammograms? Have you ever had a bone density test? Family History Mother- living deceased-cause: Father- living deceasedcause: Children: number living: Number Deceased: cause(s)/age(s): Illness Yes Which relative(s) and age of onset Diabetes Stroke Heart disease Blood clots in lungs or legs High blood pressure High cholesterol Osteoporosis (weak bones) Hepatitis HIV/AIDS Tuberculosis Birth defects Physician s notes 2

Name: Drinking or Drug problems Breast cancer Colon cancer Ovarian cancer Family History (cont.) Yes No Physician s notes Uterine cancer Mental illness/depression Alzheimer s disease other Yes No Physician s notes Social History Ever smoked? Currently smoking? Alcohol: Recreational drug use? Seat belt use? Regular exercise: Health hazards at home and at work? Have you been sexually abused, threatened, or hurt by anyone? Yes No Physician s notes Operations and Hospitalizations Reason Date Hospital Injuries Type Date Type Date 3

Patient s name: Immunizations/tests Tetanus-diptheria booster Hepatitis a vaccine Varicella vaccine Measles-mumps-rubella (MMR) vaccine Name: Date Influenza vaccine (flu shot) Hepatitis b vaccine Pneumococcal vaccine Tuberculosis (TB) skin test: result: Date Major illness Asthma Pneumonia/lung disease Kidney infections/stones Tuberculosis Sexually transmitted disease HIV/aids Heart attack/problems Diabetes High blood pressure Stroke Rheumatic fever Blood clots in lungs or legs Eating disorders Collagen vascular disease (lupus) Chickenpox Cancer Reflux/hiatal hernia/ulcers Depression/anxiety Anemia Blood transfusions Seizures/convulsions/epilepsy Bowel problems Glaucoma Cataracts Arthritis/joint pain/back problems Personal Past History of Illness Yes no Not (date) sure Physician s notes 4

Patient s name: Major Illness (cont.) Yes No Not sure Broken bones Hepatitis/yellow Jaundice/Liver disease Thyroid Disease Gallbladder Disease Headaches other Physician s notes Review of Systems Please check (x) if any of the following symptoms apply to you now or since childhood 1. Constitutional Weight loss Weight gain Fever fatigue Change in height 2. Eyes Double vision Spots before eyes Vision changes Glasses/contacts 3. Ear, nose, and throat earaches Ringing in ears Hearing problems Sinus problems Sore throat Mouth sores Dental problems 4. Cardiovascular Painful breathing Chest pain or pressure now past Not sure Physician s notes 5

Patient s name: Review of systems cont. Now Past Not sure Difficulty breathing on exertion Rapid or irregular heartbeat 5. Respiratory Wheezing Spitting up blood Shortness of breath Chronic cough 6. Gastrointestinal Frequent diarrhea Bloody stool Nausea/vomiting/indigestion constipation Involuntary loss of gas or stool 7. Genitourinary Blood in urine Pain with urination Physician s notes Strong urgency to urinate Frequent urination Incomplete emptying Involuntary/unintended urine loss Urine loss when coughing or lifting Abnormal bleeding Painful periods Premenstrual syndrome (PMS) Painful intercourse fibroids infertility DES exposure Abnormal Vaginal Discharge 8. Musculoskeletal Muscle weakness Muscle or joint pain 9. Skin Rash Sores Dry skin Moles 6

Name: Review of Systems (cont.) Now Past Not sure Physician s notes 10. Breasts Pain in breast Nipple discharge Lumps 11. Neurologic Dizziness Seizures Numbness Trouble walking Severe memory problems Frequent or severe Headaches 12. Psychiatric Depression or frequent crying Severe anxiety 13. Endocrine Hair loss Heat/cold intolerance Abnormal thirst Hot flashes 14.Hematologic/Lymphatic Frequent bruises Cuts do not stop bleeding Enlarged lymph nodes (glands) 15. Allergies (food and other environmental) Please list all allergies and type of reaction: Signature of Patient: Date reviewed by physician with Patient: Physician Signature: Annual Review of History: Physician Sign: Physician Sign: Physician Sign: Physician Sign: 7

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