Medical Intake
Email Address (required field)
Phone (required field) 
Date
Name (required field)
Address
City
State
Zip
Age
Height
Weight
Birth Date
Sex

Personal Physician
Referred by
Main Problem(s)
Other concurrent therapies

 

Past Medical History (Include dates for any items checked)
Significant Illnesses
Cancer Date & Explain Diabetes Date & Explain
High blood pressure Date & Explain Heart disease Date & Explain
Hepatitis Date & Explain HIV Date & Explain
Rheumatic fever Date & Explain Thyroid disease Date & Explain
Seizures Date & Explain Other Illnesses
Surgeries
Significant Trauma
Auto accident Date & Explain Falls Date & Explain
Other Traumas
Birth History
Prolonged labor Date & Explain Forceps delivery Date & Explain
Other birth history
Allergies
Drugs Date & Explain Chemicals Date & Explain
Foods (please list)
Medicines taken within the past two months (include vitamins, over the counter drugs, herbs, etc.)
Occupational stresses (Chemical, physical, psychological, etc.
Physical exercise (Please indicate type of exercise, how many times a week & how long)
Additional comments
Average daily diet (briefly describe)
Morning
Afternoon
Evening
Personal Habits
Cigarettes Coffee Tea Cola
Alcohol Drugs Sugar Salt
Dairy Chocolate
Family Medical History
Diabetes Date & Explain Cancer Date & Explain
High blood pressure Date & Explain Heart disease Date & Explain
Stroke Date & Explain Seizures Date & Explain
Asthma Date & Explain Allergies Date & Explain
Alcoholism Date & Explain Other Family History

 

Please check and or fill in to the best of your ability
General
Poor appetite Heavy appetite Poor Sleep Heavy sleep
Insomnia Fatigue Tremors Vertigo
Cold hands Cold feet Cold back Cold abdomen
Fevers Chills Night sweats Sweat easily
Cravings Localized weakness Poor coordination Change in appetite
Sudden energy drop at (time) Peculiar tastes/smells (explain)
Strong thirst (cold/hot drinks) (explain) Bleed or bruise easily (where)
Skin and Hair
Rashes Ulcerations Hives Itching
Eczema Pimples Dandruff Loss of hair
Changes in hair/skin texture Purpura Other hair or skin problem (explain)
Head, Eyes, Ears, Nose, and Throat
Dizziness Concussions to head Migraines Glasses
Eye strain Eye pain Poor vision Night blindness
Color blindness Cataracts Blurry vision Earaches
Ringing in ears Poor hearing Nose bleeds Sinus problems
Mucus Dry throat Dry mouth Copious saliva
Teeth problems Jaw clicks Grinding teeth Facial pain
Gum problems Spots in eyes Recurrent sore throats /month (how often)
Sores on lips or tongue Dry eyes Headaches (where and when)
Other head or neck problems (explain)
Cardiovascular
High blood pressure Low blood pressure Chest Pain Irregular heartbeat
Dizziness Fainting Cold hands/feet Swelling in hands/feet
Blood clots Phlebitis Difficulty breathing    
Other (explain)
Respiratory
Cough Coughing blood Asthma Bronchitis
Pneumonia Difficulty in breathing when lying down Tight chest    

Production of Phlegm (what color and what amount)

Other lung problems (describe)
Gastrointestinal
Nausea Vomiting Diarrhea Pain or cramps
Gas Belching Black Stools    
Bad Breath Rectal pain Hemorrhoids    
Constipation Bloody Stools Sensitive abdomen    
Laxative use: times per week. What type:
Bowel Movement: (how often)
Genito-Urinary
Pain on urination Frequent urination Blood in urine Urgency to urinate
Unable to hold urine Kidney stones Venereal disease Impotency
Wake up to urinate Describe How many times per night and what times
Pregnancy and Gynecology
Number of pregnancies: Number of children:
Flow (describe)
Irregular periods Last PAP
Vaginal discharge Vaginal sores Breast lumps
Premature births Miscarriages Clots
Birth control: type and duration Changes in body/ emotion, prior to menstruation
Age at first menses Menopause
Period (days)
Last menses
Musculoskeletal
Neck pain Muscle pains Back pain (where)
Joint pains (where) Other joint or bone problems?
Neuropsychological
Seizures Areas of numbness Poor memory Concussion to head
Depression Anxiety Bad temper Easily stressed
Treated for emotional problems Considered/attempted suicide
Other neurological or psychological problems? (describe)

 

Preferences
Preference Most Liked Least Liked
Season
Taste
Climate
Time of Day
Temperature
What emotion do you feel most? Briefly explain:
Anger
Joy/Sorrow
Sympathy
Worry/Grief
Fear