New Patient Intake forms

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Address* This field is required.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number* This field is required.
Area Code
Phone Number
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Gender* This field is required.
Male
Female
7
How Did You Hear About Our Office?
8
Emergency ContactWho would you like us to contact in the case of an emergency?
Name
Relationship
Please enter their phone
9
What is your major complaint?* This field is required.Be as specific as possible
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Ok
Ok
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When did your condition/symptoms/pain first appear?
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How motivated are you to make changes to your health?
12
General Information
Weight
Height
Single
Married
Divorced
Widowed
Marital Status
Occupation/Job Title
13
Since the onset of your problem is it:
Getting worse
Staying the same
Slow to improve
Comes and goes
14
When is it Worse?
Morning
Afternoon
Evening
N/A
15
Does it Interfere With:
Work
Sleep
Daily Routines
Other
16
Other Physicians Seen for This Condition:Including alternative or complimentary practitioners
Name
Specialty
Name
Speciality
Name
Speciality
Name
Speciality
17
Personal Medical HistoryGastrointestinal:
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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N/A
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Personal Medical History cont.Cardiovascular
Past condition
Ongoing condition
N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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Personal Medical History cont.Genital & Urinary system
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Herpes - genital
Other
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Herpes - genital
Other
Past conditon
Ongoing condition
N/A
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Past conditon
Ongoing condition
N/A
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Personal Medical History cont.Musculoskeletal/Pain
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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Personal Medical History cont.Inflammatory/Autoimmune
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Food allergies
Environmental allergies
Multiple chemical sensitivites
Latex allergy
Other
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Food allergies
Environmental allergies
Multiple chemical sensitivites
Latex allergy
Other
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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N/A
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N/A
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Personal Medical History cont.Metabolic/Endocrine
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Hashimoto's
Weight gain
Weight loss
Eating disorder
Polycystic Ovarian Syndrome
Infertility
Other
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Hashimoto's
Weight gain
Weight loss
Eating disorder
Polycystic Ovarian Syndrome
Infertility
Other
Past condition
Ongoing condition
N/A
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N/A
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Personal Medical History cont.Respiratory
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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N/A
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Ongoing condition
N/A
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N/A
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Ongoing condition
N/A
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Ongoing condition
N/A
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Personal Medical History cont.Skin
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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Personal Medical History cont.Cancer
Past condition
Ongoing condition
N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
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Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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Personal Medical History cont.Neurological
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Past condition
Ongoing condition
N/A
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N/A
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N/A
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Ongoing condition
N/A
Past condition
Ongoing condition
N/A
Past condition
Ongoing condition
N/A
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Family History
Mother
Father
Sibling
Children
Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
Mother
Father
Sibling
Children
Grandparent
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28
Please list any significant physical trauma you've experienced:(i.e. car accidents, sport injuries, head injuries, etc.)
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Small
Ok
Ok
29
Please list emotional trauma you've experienced in your life:
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Ok
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Gynecological history (for women only)Please provide a number for each area:
Pregnancies
Miscarriage(s)
Abortions
Living Children
31
Gynecological Hx cont.Birth control
Present use
Past use
Never
Birth control pills
Birth control pills
Present use
Past use
Never
32
Gynecological Hx cont.Women's disorders/hormonal imbalances. Choose all that apply
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
33
Menopausal patientsCheck all that apply.
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
34
Smoking
Current smoker?
If yes, how many years?
If yes, packs per day
35
Alcohol1 drink = 5oz wine, 12oz beer, 1.5oz spirits
How many drinks currently per week (give range 1-3, 4-6)
36
Caffeine
Caffeine intake Y/N?
Cups of coffee per day
Cups of caffeinated tea per day?
Soda/Diet soda intake Y/N?
Amount per day
37
How Many Hours Per Week Do You Typically Work/Attend School?
< 20 Hours
20 Hours
30 Hours
40 Hours
40+ Hours
38
Do You Exercise?If yes, how often and what type?
39
How Would You Rate Your Eating Habits?
Excellent
Pretty Good
Could Be Better
Needs Improvement
40
Do You Follow a Specific Nutritional Program?If yes, what type?
41
Would You Like Help With Your Diet or Have a Nutritional Program Developed For You?
YESNO
42
How Well Do You Sleep?
Excellent
Pretty Good
Restless
Can't Sleep
43
How Many Hours of Sleep Do You Get Nightly?
44
Do You Feel Well Rested in the Morning?
YESNO
45
Do You Have Any Allergies?Food, Contact, Environmental
46
List and Prescribed Medications, Over the Counter Medications, Vitamins, Herbs, and Supplements You Are Taking
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Ok
47
Please list your wellness goals:What do you hope to achieve while working with us?
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Ok
48
Injuries/Surgeries You've Had and When
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Ok
49
HIPPA Agreement* This field is required.
50
Consent for Treatment* This field is required.
51
Patient or Guardian Signature* This field is required.
Clear
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