INTAKE FORM

Congratulations! You have decided to take another step to take charge of your wellness. You may skip questions you are not sure of or not ready to answer. Please keep in mind by providing as much information as possible will allow us to help you to reach your goals. This is information gathering so there are no wrong answers. The intention behind each question is to learn how we can help to optimize your health. Get ready for a customized experience tailored just for you!
First Name
Last Name
Gender
Age
DOB
MM-DD-YYYY
Complete Date Of Birth

MonthDayYear
Date
Home Address
Street, City, State, Zip
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Billing Address
Billing Zip
Occupation
Marital Status
Name and ages of children
How did you hear about us?
May we give you appointment reminder calls/text?
May we leave you phone messages?
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship of Contact:
Name of Medical Doctor/ Family Physician

Name

Phone

Date of last blood workDate of last annual / physical exam

List any other health care providers (name, specialty and phone):
List your 5 health concerns in order of importance to you:
Has any health concern recently changed or become worse? If yes, please explain.
Has you doctor diagnosed you with any condition(s) (currently & previously?)
Have you had Covid-19 vacinne?
Please list all current medications (prescription or over-the-counter) Include supplements such as herbs, vitamins and programs.
List past prescription medications:
List any known allergies (include drugs, food, environmental, chemical ect... and what is the reaction from them.
Do you use the following? Check all that apply.

coffeesoft drinksArtificial SweetenersTabaccoAlcoholRecreational DrugsPain KillersSteroidsLaxativesAnalgesicsAntacidsOther
Present Weight
Weight one year ago
Maximum weight and when
Minimum adult weight and when
Ideal weight
Height:
List any surgeries and the date(s).
List physical trauma(s) and date(s) of incident.
List any mental or emotional traumas:
X-Rays:
MRI: when and why did you have them?
ULTRASOUNDS: when and why did you have them?
TUBERCULOSIS TEST: when and why did you have them?
CAT SCANS: when and why did you have them?
LAST DENTAL WORK: when and why did you have them?
HIV TEST: when and why did you have them?
LAST EYE EXAM: when and why did you have them?
THE FOLLOWING SERIES OF QUESTIONS ARE FOR MALES ONLY.
FOR MALES: Are you currently sexually active?
FOR MALES: Have you been sexually active in the past?
FOR MALES: Do you use forms of contraception?
FOR MALES: Do you have regular prostate exams
FOR MALES: Do you have any sexual problems or concerns? If yes, please explain.
FOR MALES: Do you have difficulty urinating completely?
FOR MALES: How many times do you get up from your sleep to go to the bathroom?
THE FOLLOWING SERIES OF QUESTIONS ARE FOR FEMALES ONLY.
FOR FEMALES: Date of last period?
FOR FEMALES: Age at first period?
FOR FEMALES: Are you pregnant?
FOR FEMALES: Are you currently sexually active?
FOR FEMALES: Do you use birth control?
FOR FEMALES: Number of live births
FOR FEMALES: Number of miscarriages
FOR FEMALES: Number of abortions
FOR FEMALES: Date of last pap smear (approximate is okay)

MonthDayYear
Date
FOR FEMALES: Was there any issues with your pap smear results?
FOR FEMALES: Date of last bone density/scan (approximate is okay)

MonthDayYear
Date
FOR FEMALES: Was there any issues with the results of your bone density/scan?
FOR FEMALES: Date of last mammogram (approximate is okay)

MonthDayYear
Date
FOR FEMALES: Was there any issues with the results of your mammogram?
FOR FEMALES: Do you perform self-breast exams monthly:
FOR FEMALES: Have you had any of the following concerning your breast?

PainLumpsInfectionscystsNipple dischargeOther concern in breast
FOR FEMALES: Do you experience any of these PMS symptoms?

CravingsbloatingBreast tendernessMood changesOther PMS symptoms
FOR FEMALES: Are you menopausal?

YesNoIf so, what are your symptoms? Your age of last period?
FOR FEMALES: Do you experience vaginal infections?
FOR FEMALES: Do you use hormones?

YesNoIf so, type and dosage?
FOR FEMALES: Do you experience bladder or kidney infections?

NeverRarelyFrequently
FOR FEMALES: Do you have any sexual problems or concerns. If yes, please explain.
Both MALE & FEMALES, please continue to fill out the questions below:
Childhood Illnesses (check all that apply)

Chicken poxScarlet feverMeaslesTuberculosisMumpsPertussisRubellaRheumatic feverAny other major childhood illness or disease
VACCINATIONS: (check all that apply)

DPT (diptheria, pertussis & tetanus)HIB (haemophilus influenza B)Varicella (chicken pox)MMR (measles, mumps & rubella)PolioGardasil (HPV)Hepatitis AHepatitis BSeasonal Flu shotTetanus BoosterRota VirusmeningococcalPneumococcalVaccinations other / unknown
If you have been treated in the past with antibiotics, what kind of condition(s) being treated?
Have you ever used probiotics after antibiotics?
FAMILY HISTORY:
If you don't know your family history, please explain why.
Do you have family members with Alcoholism/Drug abuse? type here
Which family member(s) have Alcoholism/Drug abuse?type here
Do you have family members with Epilepsy? .
Which family member(s) have Epilepsy?
type here
Do you have family members with Allergies/Hay fever? blanks.
Which family member(s) Allergies/Hay fever?
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Do you have family members with Heart disease? blanks.
Which family member(s) have Heart disease?
blanks.
Do you have family members with Arthritis? blanks.
Which family member(s) have Arthritis?
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Do you have family members with High Blood pressure? blanks.
Which family members have High Blood pressure?
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Do you have family members with Asthma/Emphysema/COPD? blanks.
Which family members have Asthma/Emphysema/COPD?
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Do you have family members with Kidney disease? blanks.
Which family members have Kidney disease?
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Do you have family members with Auto-immune disease? blanks.
Which family members have Auto-immune disease?
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Do you have family members with Liver disease? blanks.
Which family members have Liver disease?
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Do you have family members with Bleeding disorder? blanks.
Which family members have Bleeding disorder?
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Do you have family members with Mental illness? blanks.
Which family members have Mental illness?
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Do you have family members with Cancer? blanks.
Which family members have Cancer?
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Do you have family members who are Overweight/Obesity? blanks.
Which family members are Overweight?
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Do you have family members with Diabetes? blanks.
Which family members have Diabetes?
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Do you have family members that have suffered a stroke? blanks.
Which family members have suffered a stroke?
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Do you have family members with Digestive disorder? blanks.
Which family members have Digestive disorder?
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Do you have family members with Thyroid problems? blanks.
Which family members have Thyroid problems?
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Do you have family members with Eating disorder? blanks.
Which family members have Eating disorder?
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Do you have family members with any other health concerns you feel relevant? blanks.
Which family members have other health concerns you feel relevant?
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Please list what you have eaten for BREAKFAST for the past 3 days:
Please list what you have eaten for LUNCH for the past 3 days:
Please list what you have eaten for DINNER for the past 3 days:
Please list what you have eaten for SNACKS for the past 3 days:
Do you have dietary restrictions? (religious, personal, vegan, etc.)

YesNoIf so, what?
How much coffee do you drink per day?
How much water in ounces do you drink per day?
How often do you have a bowel movement?
What is the color of your stool?
1-10. One is LOW. Ten is BEST. Rate your ENERGY level:
Does you bowel movements tend to be:

ConstipationDiarrheaBothOther
What is the shape of your stool?

Well formedRibbon-likePelletsOther
If you have fatigue, when is it the worst?

MorningAfternoonEveningCan you do what you need to durning the day?
1-10. One is LOW. Ten is BEST. Rate your STRESS level:
What do you do to relieve stress?
What type of exercise do you do?
How long do you exercise?
How many hours of sleep per night?
Check all that apply

NightmaresWake up refreshedGrind teethSleepwalknap during daySnoreenjoy job
How many hours do you work per week?
Highest level of Education?
1-10. One is VERY UNHAPPY. Ten is BEST. Rate your significant relationship:
How do you spend your free time?
History of sexual, mental/emotional or physical abuse?

YesNoWhat age? by whom?
Active spiritual practice? If so, are you satisfied?
If not spiritually active, do you desire to explore this area of health?
How does your greatest health concern limit you the most?
How committed are you towards making valuable changes?
SKIN
RASH:
HIVES:
LUMP ON SKIN:
PSORIASIS/ECZEMA:
SKIN COLOR CHANGE:
ITCHY SKIN:
DRY SKIN:
WARTS/MOLES:
SKIN CANCER:
PERSPIRATION:
Head
HEADACHE:
DANDRUFF:
HEAD INJURY:
MIGRAINE:
OILY/DRY HAIR:
HAIR LOSS:
NOSE
FREQUENT COLDS:
CONGESTION:
POST NASAL DRIP:
POLYPS:
SEASONAL ALLERGIES:
NOSEBLEEDS:
EYES
DRY/WATERY:
BLURRY VISION:
DOUBLE VISION:
CATARACTS:
GLAUCOMA:
STYES:
STRAIN:
DISCHARGE:
ITCHY EYES:
DARK UNDER EYELID:
MOUTH/THROAT
CANKER SORES:
COLD SORES:
SORE THROAT:
GUM DISEASE:
Dentures:
Cavities:
Loss of tastes:
Hoarseness:
NECK
Stiffness:
Swollen glands:
Do you have full movement:
Do you have tension:
RESPIRATORY
Cough:
COPD:
Shortness of breath w/exertion:
Shortness of breath sitting:
Shortness of breath lying down:
Bronchitis:
Asthma:
Wheezing:
Pneumonia:
Painful breathing:
CARDIOVASCULAR
High blood Pressure:
Rheumatic Fever:
Low blood pressure:
Murmurs:
Arrhythmia:
Palpitations:
Edema:
Chest pain:
URINARY TRACT
Incontinence:
Pain w/urination:
Frequent Infections:
Kidney stones:
Urgency:
Discharge/blood:
GASTROINTESTINAL
Heartburn:
Parasites:
Indigestion:
Blood in stool:
Bloating:
Diarrhea:
Nausea:
Constipation:
Vomiting:
Liver disease:
Change in appetite:
Gall bladder disease:
Pancreatitis:
Ulcer:
MUSCULOSKELETAL
Weakness:
Arthritis:
Stiffness:
Leg cramps:
Tremors:
Pain:
NERVOUS SYSTEM
Paralysis:
Sciatica:
Tingling/numbness:
Carpal tunnel:
Seizures:
Fainting:
MENTAL / EMOTIONAL
Depression:
Anger/Irritability:
High strung/tense:
Anxiety:
Fear/panic:
Type a question
Eating disorder:
Psych hospitalization:
Brain Fog:
Type a question
PTSD:
Suicidal:
MISCELLANEOUS
Cold hands/feet:
Night sweats:
Phlegm:
Spontaneous sweat:
Easily awaken:
Loss of voice:
Foul breath:
Thirsty:
Hemorrhoids:
Bruise easily:
Excessive dreaming:
Bitter tasting mouth:
Brittle nail:
Sigh easily:
Oversleep:
What potential obstacles do you foresee in addressing the lifestyle factors, which are undermining your health, and in adhering to the therapeutic protocols?
What are your goals and expectations with our clinic?
Is there any other information that you feel is important that has not been covered?
Should be Empty:

SKIN

Head

NOSE

EYES

MOUTH/THROAT

NECK

RESPIRATORY

CARDIOVASCULAR

URINARY TRACT

GASTROINTESTINAL

MUSCULOSKELETAL

NERVOUS SYSTEM

MENTAL / EMOTIONAL

MISCELLANEOUS