Intake Forms Name Date Like to be called by: Mailing Address City/State Zip Code Shipping Address City/State Zip Code Phone (home) Cell Phone E-mail Emergency Contact: Phone (home/cell) Age Date of Birth Gender Female Male Higher Education Level: Occupation Referred by High School Under-Graduate Post-Graduate Media: Please indicate source Employer by Online (Google\Please list search words you used to find us Health Care Organization Friend or Family Authorization to Provide Information; this health consultation is to provide you with alternative suggestion for healthcare only. It is up to you to make your own decision on what you will do for your health regarding testing, supplements and alternative care. Signature: Print Name: Date:
This form provides a big picture to your health. We understand that this is an extensive form. Get yourself a glass of water or tea, relax, and take your time. If you could erase 3 problems, what would they be? 1. 2 3. When was the last time you felt well? Did something trigger your change in health? What makes you feel worse? What makes you feel better? PLEASE LIST CURRENT AND ONGOING PROBLEMS IN ORDER OF PRIORITY Describe Problem Mild Mod. Severe Prior Treatment Approach Example: Post Nasal drip x Elimination Diet x Good Fair Bad PAST MEDICAL HISTORY DIAGNOSIS/CONDITIONS/DISEASES This is a list of any problems you might have had or have. Please Check appropriate box and provide date. Gastrointestinal Date Irritable Bowel Genital and Urinary Skin Diseases Inflammatory Bowel Kidney Stones Eczema GERD (Reflux) Gout Psoriasis Peptic Ulcer Urinary Infections Melanoma Celiac Disease Yeast Infections Neurologic/Mood Gall Bladder Erectile/Sexual Issues Depression Cardiovascular Musculoskeletal/Pain Anxiety Heart Attack Osteoarthritis Bipolar Disorder Elevated Cholesterol Osteoporosis Schizophrenia Arrhythmia Osteopenia Memory Issues Hypertension Chronic Pain Injuries Mitral Valve Prolapse Inflammatory/Autoimmune Head Injury Endocrine Chronic Fatigue Neck Injury Type 1 or 2 Diabetes Autoimmune Disease Back Injury Pre-Diabetes Food Allergies Knee Injury Hypoglycemia Chemical Sensitivities Ankle Injury Hypothyroidism Poor Immune Function Car Accident Hyperthyroidism Herpes-Genital Surgeries Polycystic Ovarian Respiratory Disease Appendectomy Weight Gain Asthma Hysterectomy Weight Loss Chronic Sinusitis Gall Bladder Eating Disorder Bronchitis Hernia Skin Diseases Pneumonia Dental Surgery Eczema Sleep Apnea Joint replacement Psoriasis Heart Surgery Melanoma Other Cancer Explain: Explain:
Preventive Tests and Dates Full Physical Exam Bone Density Colonoscopy Blood Chemistry Panel Upper Endoscopy Upper GI Series Hemoccult (stool/blood) Test Other: Blood Type & Physical Attributes A B AB O Rh Rh+ Unknown Height (feet/inches) Current weight Usual weight range +/- 5 lbs. Desired weight range +/- 5 lbs Highest adult weight Lowest adult weight Weight fluctuations (>10 lbs.) Hospitalization If yes, list Date Reason Dental History Silver Mercury Fillings If yes, how many Tooth Pain Removal of Mercury When, how many Bleeding Gums Root Canals If yes, how many Loose Teeth Implants Grinding Teeth Gingivitis Other: CURRENT MEDICAL HISTORY MEDICATIONS Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathic) Supplement & Brand Dose Frequency Start date (mo./yr.) Reason for Use Current Medications Medication Dose Frequency Start date (mo./yr.) Reason for Use MEDICATIONS (Continue) YES NO Have your medications or supplements ever caused you unusual side effects or problems? Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin? Have you had prolonged or regular use of Acid Blocking Drugs (Tagamet, Zantac, Prilosec) Frequent Antibiotic >2 times a year or long term?
Environmental and Detoxification Assessment YES NO Do you have known significant reactions or sensitivities Cigarette Smoke Perfumed/ Colognes Auto Fumes Mold Electromagnetic Radiation Other: Do you have an adverse reaction to caffeine Do you have a known history of significant exposure to any harmful chemicals? Herbicides Pesticides Organic Solvents Heavy Metals Insecticides Other: Sleep Average number of hours you sleep per night 3-4 hr. 4-6 hr. 6-9 hr. Do you sleep well? Yes No Do you have trouble falling asleep Yes No Do you wake up at night? What Time? 11pm-1am 1am-3am 3am-5am 5am-7am What is your best time of day 8-11 am 12-4 pm 4-8 pm 8-11 pm What is your worst time of day 8-11 am 12-4 pm 4-8 pm 8-11 pm Do you use sleeping aids Yes No Explain: Do you have problems with insomnia Yes No Do you awake rested Yes No Exercise: Activity Type Frequency per week Duration of minuets Nutrition History Do you currently follow a specific diet or nutritional program Yes No Check all that apply: Low fat No Dairy Low Carbohydrates High Protein Low Sodium Diabetic No Wheat Gluten restricted Vegetarian Vegan Known food allergies: Wheat Dairy Corn Citrus Egg Alcohol Do you have any immediate symptoms in associations with eating Yes No If yes, Check all that apply: Belching Bloating Abdominal pain Diarrhea Hives Post Nasal Drip Do fatty foods cause indigestion Yes No Does skipping a meal greatly affect you Yes No Do you have delayed symptoms to eating certain foods (up to 24/48 hours) Yes No How often do you eat How many times a day Are you thirsty Yes No Elimination Habits Do you have bowel movement daily Yes No Frequent diarrhea Yes No If yes, are they explosive Yes No How many times a day? Constipated often Yes No If yes, how many days between Do you have intestinal gas Yes No Offensive odor Yes No Occasionally Daily Excessive Difficult to pass Yes No Are they: Hard Hard small balls Watery Loose Thin Float Do you have stomach or abdominal pain Yes No What color is your stool Grey Light Tan Brown Black Do you ever see blood in the stools Yes No Stress/Coping Do you have an excessive amount of stress in your life Yes No Do you feel you can easily handle the stress in your life Yes No Daily Stressors Work Family Social Finances Health Do you practice relaxation techniques or meditation Yes No Yoga Mediation Imagery Breathing Tia Chi Prayer Have you ever been abused, a victim of a crime or experienced a significant trauma Yes No
Psychosocial History Do you feel significantly less vital than you did a year ago Yes No Are you happy Yes No Do you believe stress is presently reducing the quality of your life Yes No Do you experience any of the following? Yes No Over-sympathetic: sense of despair, disgust, nervousness Yes No Low self-esteem: hopelessness, worries, distrust, live through others Yes No Rigidly positioned: defensive, crying, compelled to neatness Yes No Experiencing grief: sadness, anguish, yearning, cloudy thinking Yes No Fear: Bad memory, contemplated, impending doom, dread Yes No Resentment: emotionally repressed, depression. Indecisive, galled, stubborn Yes No Anger: aggression, irritability, frustration Yes No Lost, vulnerable: insecurities, abandoned, absent mindedness, deserted Yes No Frightfully overjoyed: lack of emotions, rapid mannerisms and speech, talkative, Yes No abnormal laughter (inappropriate) Muddled instability: lack of emotions, up and down, can t figure it out, paranoia, mudded Yes No thinking Non-thinking, non-emotions: sluggish memory, vivid dreaming, depleted, suppressed Yes No Memory Screening Forgetting where you have put something, losing things around the house Yes No Failing to recognize places that you have been before Yes No Finding a television story difficult to follow Yes No Not remembering a change in your daily routine Yes No Having to go back to check whether you have done something that you meant to do Yes No Completely forgetting to take things with you, having to go back and fetch them Yes No Forgetting that you were told something yesterday or a few days ago Yes No Starting to read something without realizing you have already read it before Yes No Having difficulty picking up a new skill, for example new game or new gadget Yes No Finding that a word is on the tip of your tongue, but you can t quite find it Yes No Forgetting details of what you did or what happened the day before Yes No When talking to someone, forgetting what you said What was I talking about? Yes No Family History Please indicate if any family member has had and/or died from any of the following: (Relationship & Age) Self Mother Father Sisters Brothers Children Gndparent (Mother s) Alcoholism Allergies Asthma Inflammatory Arthritis Inflammatory Bowel Cancer Breast Cancer Diabetes Eczema / Psoriasis Genetic Disease Glaucoma Heart Disease High Cholesterol Immune Disorder High Blood Pressure Kidney Disease Mental / Nervous d/o Osteoporosis Parkinson s Depression Schizophrenia Bipolar Disorder Stomach Ulcers Stroke Thyroid Disorders Gndparent (Father s) Aunt/Uncle
SYMPTOM SURVEY FORM INSTRUCTIONS: Check in only the boxes which apply to you. 51 Overeating sweets upsets Leave Blank in NO symptoms 52 Awaken few hours sleep hard to get back to sleep X MILD symptoms (occurred once or twice in last 6 months) 53 Craves candy or coffee in afternoon X MODERATE symptoms (occurred once or twice last month) 54 Moods of depression blues X SEVERE symptoms (chronic, occurred once or twice last week) 55 Abnormal craving for sweets or snacks GROUP 1 GROUP 4 2 Get chilled often 56 Hands and feet go to sleep easily 3 Lump in throat 57 Sigh frequently, air under 5 Pulse speeds after meals 58 High altitude discomfort 6 Keyed up fail to calm 60 Opens windows in closed rooms 7 Cut heals slowly 61 Susceptible to colds and fevers 8 Gag easily 62 Afternoon yawner 9 Unable to relax, startles easily 63 Get Drowsy often 10 Extremities cold, clammy 64 Swollen ankles, worse at night 11 Strong light irritates 65 Muscle cramps, worse exercise; charley horses 12 Urine amount reduced 66 Shortness of breath on exertion 13 Heart pounds after retiring 67 Dull pain in chest or radiation, worse on exertion 14 Nervous stomach 68 Bruise easily, black and blue spots 15 Appetite reduced 70 Nose bleeds frequently 16 Cold sweats often 71 Noises in head, or ringing in ears 17 Fever easily raised 72 Tension under breastbone, tightness worse exertion 18 Skin sensitive to touch GROUP 5 19 Staring, blinks little 73 Dizziness 20 Sour stomach often 74 Dry skin GROUP 2 75 Burning Feet 21 Joint stiffness on arising 76 Blurred vision 22 Muscle-leg-toe cramps at night 77 Itching skin and feet 23 Butterfly stomach, cramps 79 Frequent skin rashes 25 Eyes blink often 80 Bitter, metallic taste in mouth in morning 24 Eyes or nose watery 81 Bowel movement painful or difficult 26 Eyelids swollen, puffy 82 Worrier feels insecure 27 Indigestion soon after eating 83 Feels queasy; headache over eyes 28 Always seems hungry; lightheaded often 84 Greasy food upset 29 Digestion rapid 85 Stools light colored 30 Vomiting frequent 86 Skin peels on foot soles 31 Hoarseness frequent 87 Pain between shoulder blades 32 Breathing irregular 88 Use laxatives 33 Pulse slow; feels irregular 89 Stools alternating from soft to watery 34 Gagging reflex slow 90 History of gallbladder attach sot gallstones 35 Difficulty swallowing 91 Sneezing attacks 36 Constipation, diarrhea alternation 92 Dreaming, nightmares type bad dreams 37 Slow starter 93 Bad breath (halitosis) 38 Gets chilled infrequently 94 Milk products causes distress 39 Perspire easily 95 Sensitivity to hot water 40 Circulation poor, sensitive to cold 96 Burning or itching anus 41 Subject to colds, asthma, bronchitis 97 Craves sweets GROUP 3 GROUP 6 42 Eat when nervous 98 Loss of taste for meat 43 Excessive appetite 99 Lower bowel gas several hours after eating 44 Hungry between meals 100 Burning stomach sensation, eating relieves 45 Irritable before meals 101 Coated tongue 46 Get shaky if hungry 102 Pass large amounts of foul-smelling gas 47 Fatigue, eating relieves 103 Indigestion ½-1 hours after eating; up to 3-4 hours 48 Lightheaded if meals delayed 105 Gas shortly after eating 49 Heart palpated if meals missed or delayed 106 Stomach bloated after eating 51 Overeating sweets upsets Dr. Keri Brown, N.D. Wide Awake Wellness www.drkeribrown.com 970-889-3541 admin@drkeribrown.com pg. 6
GROUP 7 160 Nails weak, ridged 107 Insomnia 161 Tendency to hives 108 Nervousness 162 Arthritis tendencies 109 Can t gain weight 163 Perspiration increases 110 Intolerance to heat 164 Bowel disorder 111 Highly emotional 165 Poor circulation 112 Flushes easily 166 Swollen ankles 113 Night sweats 167 Craves salt 114 Thin, moist skin 168 Brown spots or bronzing of skin 115 Inward trembling 169 Allergies tendency to asthma 116 Heart palpitates 170 Weakness after colds, influenza 117 Increased appetite without weight gain 171 Exhaustion muscular and nervous 118 Pulse fast at rest 172 Respiratory disorders 119 Eyelids and face twitch GROUP 8 GROUP 7B 173 Apprehension 122 Increased weight gain 174 Irritability 123 Decreased in appetite 175 Morbid fears 124 Fatigue easily 176 Never seems to get well 125 Ringing in ears 177 Forgetfulness 126 Sleepy during the day 180 Craving for sweets 127 Sensitive to cold 181 Muscular soreness 128 Dry or scaly skin 182 Depression, feeling of dread 129 Constipation 183 Noise sensitivity 130 Mental sluggishness 184 Acoustic hallucinations 131 Hair course falls out 179 Poor appetite 132 Headaches upon arising, wear off during the day 185 Tendency to cry without reason 133 Slow pulse, below 55 186 Hair is course and/or thinning 134 Frequency of urination 187 Weakness 135 Impaired hearing 189 Skin sensitive to touch 136 Reduced initiative 190 Tendency towards hives GROUP 7C 191 Nervousness 137 Failing memory 192 Headaches 138 Low blood pressure 193 Insomnia 139 Increased sex drive 194 Anxiety 140 Headaches, splitting or rending type 196 Inability to concentrate, confusion 141 Decreased sugar tolerance 197 Frequent stuffy nose, sinus infection GROUP 7D 199 Loose joints 142 Abnormal thirst FEMALE ONLY 143 Bloating of abdomen 203 Depressed feeling before menstruation 144 Weight gain around hips or waist 204 Menstruation excessive and prolonged 145 Sex drive reduced or lacking 205 Painful breasts 146 Tendency to ulcers, colitis 200 Very easily fatigues 147 Increased sugar tolerance 201 Premenstrual tension 148 Women: menstrual disorder 202 Painful menses 149 Young girls: lack of menstrual function 208 Hysterectomy / ovaries removed GROUP 7E 209 Menopausal hot flashes 150 Dizziness 210 Menses scanty or misses 151 Headaches 211 Acne, worse at menses 152 Hot flashes 212 Depression of long standing 153 Increased blood pressure 206 Menstruate too frequently 154 Hair growth on face and body (female) 207 Vaginal discharge 155 Sugar in urine (not diabetes) MALE ONLY 156 Masculine tendencies (female) 213 Prostate trouble GROUP 7F 214 Urination difficult or dribbling or Night urination 157 Weakness, dizziness 218 Pain on inside of legs or heels 158 Chronic fatigue 219 Lack of energy or Tire too easily (221) 159 Low blood pressure 220 Migration aches and pains or Legs nervousness night Dr. Keri Brown, N.D. Wide Awake Wellness www.drkeribrown.com 970-889-3541 admin@drkeribrown.com pg. 7
Please write down any other information you deem necessary for Dr. Brown too know. Dr. Keri Brown, N.D. Wide Awake Wellness www.drkeribrown.com 970-889-3541 admin@drkeribrown.com pg. 8