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
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The Bahamas
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Bhutan
Bolivia
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Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
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Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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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
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Guinea-Bissau
Guyana
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Hungary
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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.
6
Date of Birth
Date
Month
Day
Year
7
Gender* This field is required.
Please Select
Please Select
Male
Female
8
How Did You Hear About Our Office?
9
Emergency ContactWho would you like us to contact in the case of an emergency?
Name
Relationship
Please enter their phone
10
What is your major complaint?* This field is required.Be as specific as possible
Huge
Large
Normal
Small
Ok
Ok
11
When did your condition/symptoms/pain first appear?
12
How motivated are you to make changes to your health?
13
General Information
Weight
Height
Single
Married
Divorced
Widowed
Marital Status
Occupation/Job Title
14
Since the onset of your problem is it:
Getting worse
Staying the same
Slow to improve
Comes and goes
15
When is it Worse?
Morning
Afternoon
Evening
N/A
16
Does it Interfere With:
Work
Sleep
Daily Routines
Other
17
Other Physicians Seen for This Condition:Including alternative or complimentary practitioners
Name
Specialty
Name
Speciality
Name
Speciality
Name
Speciality
18
Personal Medical HistoryGastrointestinal:
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Crohn's
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Ulcerative colitis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Peptic Ulcer disease
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
GERD (reflux)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Celiac disease
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
1 of 6
19
Personal Medical History cont.Cardiovascular
Past condition
Ongoing condition
N/A
Heart Attack
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Other Heart disease
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Stroke
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Elevated cholesterol
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Arrhythmia (irregular heart rate)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Hypertension (high blood pressure)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Rheumatic fever
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Mitral valve prolapse
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Other
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
1 of 9
20
Personal Medical History cont.Genital & Urinary system
Past conditon
Ongoing condition
N/A
Kidney stones
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Gout
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Interstitial cystitis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Frequent urinary tract infections
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Frequent yeast infections
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Erectile dysfunction
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Sexual dysfunction
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Herpes - genital
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Other
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Herpes - genital
Other
Past conditon
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past conditon
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past conditon
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past conditon
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past conditon
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past conditon
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past conditon
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past conditon
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past conditon
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
1 of 9
21
Personal Medical History cont.Musculoskeletal/Pain
Past condition
Ongoing condition
N/A
Osteoarthritis
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Fibromyalgia
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Chronic pain
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Other
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
1 of 4
22
Personal Medical History cont.Inflammatory/Autoimmune
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Autoimmune disease
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Rheumatoid arthritis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Lupus SLE
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Immune deficiency disease
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Severe infectious disease
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Poor Immune function
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Food allergies
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Environmental allergies
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Multiple chemical sensitivites
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Latex allergy
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Other
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
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
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
Past condition
Row 9, Column 0
Ongoing condition
Row 9, Column 1
N/A
Row 9, Column 2
Past condition
Row 10, Column 0
Ongoing condition
Row 10, Column 1
N/A
Row 10, Column 2
Past condition
Row 11, Column 0
Ongoing condition
Row 11, Column 1
N/A
Row 11, Column 2
1 of 12
23
Personal Medical History cont.Metabolic/Endocrine
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Type 2 Diabetes
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Hypoglycemia
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Metabolic syndrome (pre-diabetes)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Hypothyroidism (low thyroid)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Hyperthyroidism (overactive thyroid)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Hashimoto's
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Weight gain
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Weight loss
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Eating disorder
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Polycystic Ovarian Syndrome
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Infertility
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Other
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
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
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
Past condition
Row 9, Column 0
Ongoing condition
Row 9, Column 1
N/A
Row 9, Column 2
Past condition
Row 10, Column 0
Ongoing condition
Row 10, Column 1
N/A
Row 10, Column 2
Past condition
Row 11, Column 0
Ongoing condition
Row 11, Column 1
N/A
Row 11, Column 2
Past condition
Row 12, Column 0
Ongoing condition
Row 12, Column 1
N/A
Row 12, Column 2
1 of 13
24
Personal Medical History cont.Respiratory
Past condition
Ongoing condition
N/A
Asthma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Chronic sinusitis
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Bronchitis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Emphysema
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Pneumonia
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Tuberculosis
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Sleep Apnea
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Other
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
1 of 8
25
Personal Medical History cont.Skin
Past condition
Ongoing condition
N/A
Eczema
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Psoriasis
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Acne
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Melanoma
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Skin Cancer
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Other
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
1 of 6
26
Personal Medical History cont.Cancer
Past condition
Ongoing condition
N/A
Lung cancer
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Breast cancer
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Colon cancer
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Ovarian cancer
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Prostate cancer
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Skin cancer
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Other
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
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27
Personal Medical History cont.Neurological
Past condition
Ongoing condition
N/A
Depression
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Anxiety
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Bipolar disorder
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Schizophrenia
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Headaches
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Migraines
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
ADD/ADHD
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Autism
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Memory problems
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Dementia/Alzheimer's
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Parkinson's disease
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Multiple Sclerosis
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Seizures
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Other
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Past condition
Row 0, Column 0
Ongoing condition
Row 0, Column 1
N/A
Row 0, Column 2
Past condition
Row 1, Column 0
Ongoing condition
Row 1, Column 1
N/A
Row 1, Column 2
Past condition
Row 2, Column 0
Ongoing condition
Row 2, Column 1
N/A
Row 2, Column 2
Past condition
Row 3, Column 0
Ongoing condition
Row 3, Column 1
N/A
Row 3, Column 2
Past condition
Row 4, Column 0
Ongoing condition
Row 4, Column 1
N/A
Row 4, Column 2
Past condition
Row 5, Column 0
Ongoing condition
Row 5, Column 1
N/A
Row 5, Column 2
Past condition
Row 6, Column 0
Ongoing condition
Row 6, Column 1
N/A
Row 6, Column 2
Past condition
Row 7, Column 0
Ongoing condition
Row 7, Column 1
N/A
Row 7, Column 2
Past condition
Row 8, Column 0
Ongoing condition
Row 8, Column 1
N/A
Row 8, Column 2
Past condition
Row 9, Column 0
Ongoing condition
Row 9, Column 1
N/A
Row 9, Column 2
Past condition
Row 10, Column 0
Ongoing condition
Row 10, Column 1
N/A
Row 10, Column 2
Past condition
Row 11, Column 0
Ongoing condition
Row 11, Column 1
N/A
Row 11, Column 2
Past condition
Row 12, Column 0
Ongoing condition
Row 12, Column 1
N/A
Row 12, Column 2
Past condition
Row 13, Column 0
Ongoing condition
Row 13, Column 1
N/A
Row 13, Column 2
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28
Family History
Mother
Father
Sibling
Children
Grandparent
Cancers
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Colon
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Breast/Ovarian
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Heart Disease
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Hypertension
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Obesity
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Diabetes
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Stroke
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Inflammatory arthritis
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Inflammatory Bowel Disease
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Multiple Sclerosis
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Autoimmune Diseases
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Irritable Bowel Syndrome
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Celiac Disease
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Asthma
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Eczema/Psoriasis
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Food allergies/sensitivities
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Environmental sensitivities
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Dementia
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Parkinson's
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ALS or other motor neuron diseases
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Genetic disorders
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Substance abuse (alcoholism, etc.)
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Psychiatric disorders
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Depression
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Schizophrenia
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ADHD
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Austism
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Bipolar disease
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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
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Mother
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Mother
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Mother
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Mother
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Mother
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Mother
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Mother
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Mother
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Mother
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Mother
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Mother
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29
Please list any significant physical trauma you've experienced:(i.e. car accidents, sport injuries, head injuries, etc.)
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30
Please list emotional trauma you've experienced in your life:
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31
Gynecological history (for women only)Please provide a number for each area:
Pregnancies
Miscarriage(s)
Abortions
Living Children
32
Gynecological Hx cont.Birth control
Present use
Past use
Never
Birth control pills
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Birth control pills
Present use
Row 0, Column 0
Past use
Row 0, Column 1
Never
Row 0, Column 2
33
Gynecological Hx cont.Women's disorders/hormonal imbalances. Choose all that apply
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
34
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
35
Smoking
Current smoker?
If yes, how many years?
If yes, packs per day
36
Alcohol1 drink = 5oz wine, 12oz beer, 1.5oz spirits
How many drinks currently per week (give range 1-3, 4-6)
37
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
38
How Many Hours Per Week Do You Typically Work/Attend School?
< 20 Hours
20 Hours
30 Hours
40 Hours
40+ Hours
39
Do You Exercise?If yes, how often and what type?
40
How Would You Rate Your Eating Habits?
Excellent
Pretty Good
Could Be Better
Needs Improvement
41
Do You Follow a Specific Nutritional Program?If yes, what type?
42
Would You Like Help With Your Diet or Have a Nutritional Program Developed For You?
YESNO
43
How Well Do You Sleep?
Excellent
Pretty Good
Restless
Can't Sleep
44
How Many Hours of Sleep Do You Get Nightly?
45
Do You Feel Well Rested in the Morning?
YESNO
46
Do You Have Any Allergies?Food, Contact, Environmental
47
List and Prescribed Medications, Over the Counter Medications, Vitamins, Herbs, and Supplements You Are Taking
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48
Please list your wellness goals:What do you hope to achieve while working with us?
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49
Injuries/Surgeries You've Had and When
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50
HIPPA Agreement* This field is required.
51
Consent for Treatment* This field is required.
52
Patient or Guardian Signature* This field is required.
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