APPLIED KINESIOLOGY INTAKE FORM Patient Name: Date: Age: Date of Birth: Referred by: Email address: Day time phone number Address CHIEF COMPLAINT: Describe other methods used to relieve discomfort (other doctors, medicine, heat/ice) and result: Describe other symptoms you are currently suffering (headaches, nausea, intestinal distress, irritability, etc): FAMILY HISTORY: Diabetes Cancer Arthritis High Blood Pressure Heart Disease Other PAST HISTORY: Do you smoke years packs a day
Birth Control Pills how long List any other major diseases which you have suffered or are currently suffering (give dates of diagnosis): List all surgeries and hospitalizations (dates): Circle what you use: Alcohol white bread margarine antacids soda Caffeine sugar sweet & Low equal Laxatives Deli Meats Aspirin/Tylenol Tap Water KNOWN ALLERGIES: HISTORY OF TRAUMA: Describe physical, emotional trauma, and/or chemical exposures: What foods, if any disagree with you?
FOOD INTAKE FORM How many of each do you eat per week? Estimate as best as possible. Dairy Slices of wheat Bread Spinach Whole Milk Slices of Rye Bread Onions Skim Milk Slices of Corn Bread Tomatoes Butter Milk Rolls Yams Half&Half Sweet Rolls Others Yogurt Muffins Apples Cheese Pie Apricots Ice Cream Cake Bananas Eggs Cookies Dates Poultry Jell-o Grapefruit Beef Candy Oranges Pork Chocolate Pears Seafood Sweets Peaches Bacon Asparagus Pineapple Liver Beans Prunes Bologna or Cold cuts Brussels Sprouts Canned Fruits Canned Meat Broccoli Colas Peanuts Cabbage Uncolas
FOOD INTAKE CONITNUED: Peanut butter Carrots Kool aid Cereals Celery Orange Juice Sugar coated Corn Apple Juice Oatmeal Green Peas Grapefruit juice Pancakes Greens/Turnip Tomato juice Waffles Lettuce Other Crackers Parsley/Cilantro Alcoholic Beverages Rice Potatoes, white Tea: Sweet/unsweet Macaroni Potatoes, sweet coffee Spaghetti Slices of white Bread Squash, summer Caffeinated Squash winter Decaffeinated sanka Please fill in the blank. 1. Have you taken a broad spectrum antibiotic drug a. in the last 6 months b. If the response to A is no, have you ever taken antibiotics? 2. Have you had recurrent infection requiring prolonged antibiotic use? 3. Have you taken birth control pill? 4. Have you taken prednisone? 5. Have you had athlete s food, ringworm, jock itch, or other chronic fungus infections of the skin or nails? 6. Do you crave sugar? 7. Do you crave breads? 8. Do you crave alcoholic beverages? 9. Have you ever had Candida/yeast? 10. Endometriosis or infertility 11. Symptoms worse on damp, muggy days or in moldy places 12. Fatigue or lethargy 13. Poor Memory
14. Depression 15. Muscle and or joint aches or weakness 16. Abdominal pain 17. constipation 18. Diarrhea 19. Bloating, belching, or intestinal gas 20. Vaginal burning, itching or discharge 21. Premenstrual tension 22. Irritability 23. Inability to concentrate 24. Frequent mood swings 25. Recurrent rashes or itching 26. Rectal itching 27. Urgency or urinary frequency 28. Burning while urinating 29. Have you traveled outside the USA? 30. Since traveling abroad, have you had an elevated white blood count, intestinal problems, night sweats, or unexplained fever? 31. Do you drink untested or unfiltered water? 32. Do you use a microwave for cooking beef, fish, or pork? 33. Do you prefer fish or meat that is undercooked, i.e. rare or medium rare? 34. At home, do you use the same cutting board for chicken, fish and meat as you do for vegetables? 35. Have you lived with, or do you currently live with or handle pets? 36. Do you work or have children in a daycare center? 37. Do you garden or work in a yard to which cats and dogs have access? 38. Have you ever had parasites? 39. Red blood in stool? 40. Abdominal pain and cramps 41. Lower back pain 42. Gas, bloating 43. Fever 44. chronic Fatigue 45. Constipation 46. Diarrhea 47. Foul smelling stools 48. Anal itching 49. Bad breath 50. Grind teeth 51. Lethargic 52. mucus in stool 53. Lack stamina