Medical Patient Intake Form

Medical Patient Intake Form

Please take your time filling out this questionnaire completely and honestly. This questionnaire will essentially address every area of daily life from how much you sleep to what you eat and your everyday stressors. You should commit at least one hour to complete this form. Information is acquired to evaluate your health profile from an integrative medicine perspective. However, it should also be the starting point for you to begin to see habits and exposures that prevent you from obtaining optimal health.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Sex*
Sexual Orientation*
Social Security Number*
For Insurance Purposes
Contact Information
Mobile Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Address of the Primary Insured*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address

CityState

Zip Code
Pharmacy
Name of Preferred Pharmacy*
Pharmacy Cross Streets*
Pharmacy Phone Number
Please enter a valid phone number.
Current Medical Team
Primary Physician
PCP Phone Number
Please enter a valid phone number.
OB/GYN
OB/GYN Phone Number
Please enter a valid phone number.
Referred By
Emergency Contact
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Insurance

Tula Wellness & Aesthetics is only in-network with select plans. Please call your insurance to verify if we are in-network.
Name of Insurance Carrier*
Member ID#*
Group ID#*
Address from the back of your insurance card*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Primary Insured (if different than above)

First NameLast Name
Relation to Insured*
Social Security Number of Primary Insured*
Date of Birth of Primary Insured*

MonthDayYear
Date
Name of Secondary Insurance (if different than above)*
Member ID#*
Group ID#*
Address from the back of your insurance card*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health History
What brings you to Tula Wellness? What concerns about your health do you have?*
What are your health goals?*
Medical Conditions
Please list the name and diagnosis date of any current medical conditions.
Please list the name and diagnosis date of any previous or childhood medical conditions.
Women's Health History
Date of last menstrual period

MonthDayYear
Date
Menses (check all that apply)

RegularIrregularPainful PMSOther
If you checked "other" above, please describe:
Number of Children
Childrens' Ages
Age at start of periods
Age at end of periods/menopause
History of abnormal pap smears?
If Yes, please explain follow-up and treatment you received.
History of breast surgery?
If Yes, please explain.
History of hysterectomy or pelvic surgery?
If Yes, please explain.
Hormone Replacement Therapy
Have you ever used hormone replacement therapy?
If yes, list medications, dose, directions and the duration of the treatment.
Did you have any problems? If yes, please explain.
Diagnostic Studies
Date of last mammogram:

MonthDayYear
Date
Mammogram Results:
Date of last pap smear:

MonthDayYear
Date
Pap smear results:
Have you ever had additional diagnostic studies?*

Yes (please provide information below)No
Last Date Done & Results (-/+)

Please list a date and positive or negative (+/-) for any applicable diagnostic studies below.
Colonoscopy
Year
Result

-+
Bone Density
Year
Result

-+
Electrocardiogram
Year
Result

-+
Other (specify below)
Testing:
Year
Result

-+
Surgeries & Hospitalizations
Procedure & Date
Procedure & Date
Procedure & Date
Allergies
Do you have an ALLERGY to a drug or other substance?*
If yes, please describe all.
Current Prescription Medications
Drug Name(s), Strength(s), Dosage(s). If none, please write NONE.*
Supplements and Over-The-Counter
Drug Name(s), Strength(s), Dosage(s). If none, please write NONE.*
Family Health History

Please tell me about your family. Please include any family member with a history of tuberculosis, diabetes, cancer, emphysema, kidney disease, ulcer, nervous breakdown or gall bladder disease.
Mother:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Father:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Relationship:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Relationship:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Additional information related to your Family Medical History you would like me to know:
Social and Socioeconomic History
Occupation:
Employer:
Highest Degree Earned:
Do you enjoy your job?
Why? / Why not?
Present Marital Status:*
Spouse/Partner's Name:
Total # in household, including your children?*
What are your main interests and hobbies?
Habits & Lifestyle
Alcohol Use*

YesNo
If yes, what kind?
If yes, how many per week?
Tobacco Use*

YesNo
If yes, what kind?
If yes, how many per week?
Recreational Drug Use*

YesNo
If yes, what kind?
If yes, how many per week?
Have you ever felt that you ought to cut down on your drinking or drug use?*
Do you get annoyed at criticism of your drinking or drug use?*
Do you ever feel guilty about your drinking or drug use?*
Do you ever drink for an early morning "eye opener"?*
Do you feel safe in your surroundings?*
Do you have a history of sexual abuse?*
Sexual Activity
Sexual Orientation
Are you sexually active?
Birth Control Method?
Sexually Transmitted Infections?
Do you practice safe sex?
Men's Health History

Have you had any of the following procedures/exams? If yes, what was the date/result?
PSA?
Prostate Exam?
Vasectomy?
Sexually transmitted infections?
Cardiovascular Health:
Do you use Nitrates for chest pain?

NoYes
Sexual Dysfunction
Do you have trouble starting or maintaining an erection?
If yes, have you used any medications for it? If so, what did you use?
Did it help? If no, please explain.
Do you have a family history of any of the following?
Prostate Cancer?
Testicular Cancer?
Average hours per night of sleep:*
Average hours per day of television:*
Average hours per day of reading:*
What do you do to relax/recreate/socialize/cope with stress?*
What are the major stressors in your life?*
When are you happiest? What gives you joy?*

Describe your energy level throughout a typical day rating on a scale of 1-10: 1=Extreme Fatigue 10=Feeling Great and Energized*

	1-10
Early Morning
Mid Morning to Noon
Mid Afternoon
Evening

Please describe any associated food or drink cravings (sugar, coffee, cola, etc):*
Please check any practices you have tried:

AcupunctureFastingYogaNutritional MedicineHerbal MedicineAyurvedic MedicineNaturopathic MedicineNeuro-Linguistic ProgrammingOrthomolecular BiofeedbackChelation TherapyLight TherapyGuided ImageryHypnosisTraditional Chinese MedicineAromatherapyMeditationEnvironmental MedicineBodyworkOther
If you checked "other," please describe:
Emotional Well Being
How well have things been going for you at school?*
How well have things been going with close friends?*
How well have things been going for you with your children?*
How well have things been going for you at your job?*
How well have things been going for you with sex?*
How well have things been going for you with your parents?*
How well have things been going for you with your social life?*
How well have things been going for your attitude*
How well have things been going for you with your spouse/partner?*
Nutrition Evaluation

Please list all foods and drinks you have consumed in the past 24 hours. Include meals, snacks, beverages and condiments.
Food items; How prepared (baked, fried, etc); Amount (cups, ounces, etc):*
Is this a typical day?*

NoYes
Are you currently on a special diet?*

NoYes
If yes, please describe:
Do you have symptoms immediately after eating such as bloating, sneezing, hives, etc.?*

NoYes
If yes, are these symptoms associated with any particular food or supplement(s)?*

NoYes
Please name the food or supplement and the symptom(s); e.i. Milk = gas, diarrhea
Do you feel you have delayed symptoms after eating certain foods? (symptoms may not be evident for 24 hours or more) Symptoms include: fatigue, muscle aches, sinus, congestion, etc.*

NoYes
Review of Systems

Please check any current symptoms you may have:
Constitutional

Recent FeverNight SweatsHot FlashesUnexplained Weight Loss/GainDecline in Libido
Cardiovascular

Chest Pains/DiscomfortPalpitationsShort of breath with Exertion
Respiratory

Cough/WheezeCoughing up Blood
Sexual Function

Pain with IntercourseVaginal DrynessDecrease Sexual DesireInability to OrgasmOther
Genitourinary

Painful/Bloody UrinationLeaking UrineNighttime UrinationUnusual Vaginal BleedingFrequent Urination
Skin

RashNew or Change in MoleThin, Ridged, Splitting or Crumbling Nails
Psychiatric

Anxiety/StressSleep ProblemsDepressionIrritability
Eyes

Changes in Vision
Gastrointestinal

Heartburn/RefluxBlood or Change in Bowel MovementNausea/Vomiting/Diarrhea/ConstipationPain in Abdomen/PlevisIrritable Bowel Syndrome/Digestive ProblemsFecal Incontinence
Blood/Lymphatic

Unexplained LumpsEasy Bruising/Bleeding
Neurological

HeadachesMemory LossFainting
Ear/Nose/Throat

Difficulty HealthHay Fever/AllergiesTrouble Swallowing
Musculoskeletal

Muscle/Joint PainRecent Back Pain
Endocrine

Cold/Heat IntoleranceIncreased Thirst/Appetite
Signature

Clear
Should be Empty:

Medical Patient Intake Form

Contact Information

Pharmacy

Current Medical Team

Referred By

Emergency Contact

Insurance

Health History

Medical Conditions

Women's Health History

Hormone Replacement Therapy

Diagnostic Studies

Last Date Done & Results (-/+)

Colonoscopy

Bone Density

Electrocardiogram

Other (specify below)

Surgeries & Hospitalizations

Allergies

Current Prescription Medications

Supplements and Over-The-Counter

Family Health History

Mother:

Father:

Social and Socioeconomic History

Habits & Lifestyle

Sexual Activity

Men's Health History

Cardiovascular Health:

Sexual Dysfunction

Do you have a family history of any of the following?

Emotional Well Being

Nutrition Evaluation

Review of Systems