Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.

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Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should we Thank? (Full name) DOB Age Male Female Home Address Apt # Mobile Number City State Zip Employer Work Number Work Address City State Zip Social Security Number Email Address Emergency Contact Name Relationship Emergency Contact Number Insurance Information Primary Insurance Carrier Group Number ID Number Primary Insured Employer Name Business Address Employee Social Security Number Employee Date of Birth Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today. Concern Symptoms Onset/Duration

Symptoms Please use the following to best describe your primary issues and when they began or how long they have been a concern Health Issue Symptoms Onset/Duration Medications and Supplements Please list all medications and supplements that you take on a regular basis. Medication Supplement Purpose Dose Frequency Response Allergies Please list any allergies to supplements, medications, foods, or environmental substances: Allergy Reaction Medical History Please detail any hospitalizations and/or surgeries you have had: Reason for Hospitalization &/or Surgery Outcome Date Please detail any hospitalizations and/or surgeries you have had: Illness Date of Onset Date of Resolution

Are you presently under the care of a physician, chiropractor, naturopath, acupuncturist, or other health practitioner? Practitioner Specialty Location Telephone Women Age of menstrual onset? Last menstrual period? Are your periods regular? Days between periods? Duration of period? Number of pregnancies/children? Health Maintenance Please list the date of the most recent of the following, and bring whatever results you may have with you to your appointment. Date Date Date Complete physical Vision test WOMEN: EKG Tetanus booster Pap smear Cardiac stress test Hepatitis B vaccine Mammogram MRI/CT Breast Exam X-rays MEN: Bone density Dental Prostatic exam Cholesterol test PSA blood test CHILDREN: Stool blood test Bone density Immunizations Colonoscopy Personal Habits TOBACCO: Do you currently or have you ever smoked? If yes, what? How much? How long? When did you quit? ALCOHOL: Do you currently drink alcohol? Have you ever had a drinking problem? Do you still regularly attend meetings of any kind? If so, what and how often? If yes, how long sober? What kind of meeting?

RECREATIONAL DRUGS: Do you use recreational drugs? Have you ever used intravenous drugs? Have you ever been treated for a drug problem? EXERCISE: 30 E. 60 th Street #302 - New York, NY 10022 If so, which ones? If yes, when was the last time? Are you still in treatment? Do you currently exercise? How often? Session Length? What exercise do you do? MISCELLANEOUS: Do you drink coffee? How many 8 ounce cups per day? Do you take laxatives? Which kinds? How often? Do you use antacids? Which kinds? How often? How many hours of sleep do you get each night? Do you have problems falling or staying asleep? Do you wake frequently? Are you sexually active? What time? Do you feel rested in the am? Do you have night sweats? Do you use condoms during sexual intercourse? Family History Please list ages, health problems and cause of death if deceased: Family Member Living (age) Health Issue(s) Deceased (age) Cause Mother Father Brother(s) Sister(s) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Please circle your pain (no pain) 0 1 2 3 4 5 6 7 8 9 10 (worse pain) The pain is: Using the symbols below, mark on the pictures where you feel pain Sharp Moving Stabbing Fixed Pain: x Burning Constant Numbness: o Shooting Intermittent Electric Cramping Throbbing Aching Dull What makes the pain WORSE: Pressure Cold Sitting Stretching Heat Lying Exercise Standing Other Walking What makes the pain BETTER: Pressure Cold Sitting Stretching Heat Lying Exercise Standing Other Walking Have you ever had an accident? Auto / (Mo./Yr) Work / (Mo./Yr) Other / (Mo./Yr) None How do these conditions impair your daily activities?

Symptoms Present Past Symptoms Present Past Anxiety Lights Bother Eyes Arthritis Loss of Balance Asthma Menopause Bleeding Disorder Menstrual Cramps Blood Thinning Medication Metal Implants Cancer Muscular Aches Carpal Tunnel Loss of Memory Chest Pains Neck Pain Cold Hands/Feet Neck Stiff Constipation Neurologic Disorders Depression Pacemaker Diabetes Pain between Shoulders Diarrhea Pain in Hands or Arms Digestive/Stomach Upset Pain in Legs/Ankle/Feet Dizziness Ringing in Ears Epilepsy Seizures Fatigue Shortness of Breath Headaches Sinus Issues Heart Disease Stress Heartburn/Reflux Tension Hepatitis Tingling/Numbness High Blood Pressure Upper Back pain High Fever Loss of Smell or Taste HIV Sleeping Problems Hormone Imbalance Pregnancy Irritability Shoulder Pain Jaws/TMJ problems Nervousness Joint Swelling Other Kidney Disease Other I, hereby certify that the statements and answers given on this form are accurate to the Patient Name (Print) best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation. Signature Date

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