RHC Health History Intake

RHC Health History Intake
This information is HIPPA protected and will not be shared. It is utilized to determine any contraindications to the products you are requesting to purchase. For any questions, please email: RHCTeam@rhcliving.com
Date Today

MonthDayYear
Date
Patient Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Age*
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Current Height (Inches)*
Current Weight (lbs)*
Occupation
Are you pregnant?

YesNoNot Applicable
List all current health concerns:
When was your last physical & were there any abnormal findings?
List any laboratory procedures/tests and outcomes:
Current medications:
Current supplements/remedies:
List any major hospitalizations, surgeries and/or injuries. Please include any complications and dates:
Please list your current, primary provider and their contact information:
On a scale of 1 to 10 how would you rate the level of stress you're experiencing, with 1 being the least and 10 being the most stressed?
Do you consider yourself:
Have you had an unintentional weight loss or gain of 10 pounds or more in the last 3 months?
Is your job associated with potentially harmful chemicals? For example, pesticides, radioactivity, solvents, etc. If so, which harmful chemicals/substances have you been in contact with?
Is your job associated with health threatening or life threatening activities? For example, fireman, farmer, minor, etc. If so, which activities?
Do you have/use any of the following:

Corrective LensesDenturesHearing AidMedical Devices/Prosthetics/Implants: If yes, describe below.
Describe medical devices, prosthetics, implants (if applicable):
Are there any recent changes in your ability to:

SeeHearTasteSmellFeel hot/cold sensationsMove around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers, etc.)
Do you have a strong LIKE for any of the following flavors:

SourBitterSweetRich/FattySpicy/PungentSalty
Do you have a strong DISLIKE for any of the following flavors:

SourBitterSweetRich/FattySpicy/PungentSalty
Do you prefer:
Is your sleep disturbed at the same time every night? If yes, what time? If no, comment N/A.
Select the time of day you feel the WORST, or your symptoms are most aggravated?

7am - 9am9am - 11am11am - 1pm1pm - 3pm3pm - 5pm5pm - 7pm7pm - 9pm9pm - 11pm11pm - 1am1am - 3am3am - 5am5am - 7am
Select the time of day you feel the BEST, the most energy, or your symptoms are least aggravated?

7am - 9am9am - 11am11am - 1pm1pm - 3pm3pm - 5pm5pm - 7pm7pm - 9pm9pm - 11pm11pm - 1am1am - 3am3am - 5am5am - 7am
Do you experience any of these symptoms EVERY DAY? If so, check the box(es) that apply.

Debilitation FatigueDepressionDisinterest in EatingDisinterest in SexShortness of BreathPanic AttacksHeadachesDizzinessInsomniaNauseaVomitingDiarrheaConstipationFecal IncontinenceUrinary IncontinenceLow Grade FeverChronic Pain and/or InflammationBleedingDischargeItching/Rash
Medical History (check any/all that apply)

ArthritisAllergies/Hay FeverAsthmaAlcoholismAlzheimer's DiseaseAutoimmune DiseaseBlood Pressure ProblemsBronchitisCancerChronic Fatigue SyndromeCarpal Tunnel SyndromeCholesterol, elevatedCirculatory ProblemsColitisDental ProblemsDepressionDiabetesDiverticular DiseaseDrug AddictionEating DisorderEpilepsyEmphysemaEyes, Ears, Nose, Throat ProblemsEnvironmental SensitivitiesFibromyalgiaFood IntoleranceGastroesophageal Reflux DiseaseGenetic DisorderGlaucomaGoutHeart DiseaseChronic InfectionInflammatory Bowel DiseaseIntellectual Developmental DisorderIrritable Bowel Syndrome (IBS)InfertilityKidney or Bladder DiseaseLearning DisabilitiesLiver or Gallbladder Disease (Stones)Mental IllnessMigraine HeadachesNeurological Problems (Parkinson's, Paralysis, etc.)Sinus ProblemsStrokeSexually Transmitted DiseaseThyroid TroublesObesityOsteoporosisPneumoniaSeasonal Affective DisorderSkin ProblemsDecreased Sex DriveTuberculosisUlcerUrinary Tract InfectionVaricose VeinsOther, describe below
Describe any other conditions
Family Health History (parents and siblings)

ArthritisAsthmaAlcoholismAlzheimer's DiseaseCancerDepressionDiabetesDrug AddictionEating DisorderGenetic DisorderGlaucomaHeart DiseaseInfertilityIntellectual Development DisorderLearning DisabilitiesMental IllnessMigraine HeadachesNeurological (Parkinson's, Paralysis)ObesityOsteoporosisStrokeSuicideOther, describe below
Describe any other family medical history conditions
Medical History (MEN ONLY)

Benign Prostatic Hyperplasia (BPH)Prostate Cancer
Medical History (WOMEN ONLY)

Menstrual IrregularitiesEndometriosisFibrocystic BreastsFibroids/Ovarian CystsPremenstrual Syndrome (PMS)Breast CancerPelvic Inflammatory DiseaseVaginal InfectionsSurgical MenopauseMenopause
Age of First Period
Date of last gynecological exam:
Form of Birth Control (if any. If not, type N/A)
Date of Last Menstrual Cycle
Average Length of menstrual cycle (in days)
Interval of Time Between Menstrual Cycles (in days)
Number of Children
Number of Pregnancies
Date(s) of C-Section, if applicable
Describe any recent changes in menstrual flow (heavier, lighter, large clots, scanty, etc.)
THE FOLLOWING ARE FOR MEN AND WOMEN TO ANSWER: Tobaccos Use (# of times per day)
Alcohol (wine/liquor/beer, servings per WEEK)
Caffeine Use (coffee/tea/soda, servings per DAY)
Water Intake (How many ounces of water do you drink per DAY)
EXERCISE: Select any/all that apply:

In general, I exercise 1-2 days per weekIn general, I exercise 3-4 days per weekIn general, I exercise 5-6 days per weekI usually exercise for less than 30 minutes per workoutI usually exercise for 30-45 minutes per workoutI usually exercise for 45 minutes or more per workoutWhen I exercise, I like to walkWhen I exercise, I like to run, jog, jump rope (cardio)When I exercise, I like to weight liftWhen I exercise, I like to swimWhen I exercise, I like to do martial arts or boxingWhen I exercise, I like to do yoga
Nutrition & Diet (check all that currently apply)

Mixed Food Diet (animal and vegetable sources)VegetartianVeganSalt RestrictionFat restrictionStarch/Carbohydrate restrictionGluten restriction/eliminationTotal Calorie restrictionDairy restriction/eliminationSugar restriction/eliminationCorn restriction/eliminationEgg restriction/eliminationSoy restriction/elimination
If your diet is not described above, please describe it below:
Number of servings per day of FRUIT (citrus, melons, berries, etc.)
Number of servings per day of DARK GREEN or DEEP YELLOW/ORANGE VEGETABLES:
Number of servings per day of GRAINS (unprocessed):
Number of servings per day of BEANS, PEAS, LEGUMES:
Number of servings per day of MILK/DAIRY:
Number of servings per day of MEAT, POULTRY, FISH:
Number of servings per day of EGGS:
Number of servings per day of PROCESSED FOODS:
Check any/all eating habits that apply to you:

Skip breakfastTwo meals/dayOne meal/dayGraze (small frequent meals)Food rotationEat constantly (whether hungry or not)Generally eat on the runAdd salt to foodIntermittent FastingEat late at night
Current Supplements (check all that apply):

Multivitamin/MineralVitamin CVitamin DVitamin EEPA/DHAEvening Primrose/GLACalciumMagnesiumZincIronVitamin BDigestive EnzymesAmino AcidsCoQ10Antioxidants (Lutein, Resveratrol, etc.)Herbal TeaHerbal ExtractsChinese HerbsAyurvedic HerbsHomeopathyBach FlowersProtein ShakesNutridyn Fruits & GreensSuperfoods (bee pollen, phytonutrient blends, spirulina, etc.)ProbioticsLiquid Meals/Meal Replacement ShakesOther, please list below
Please list any current supplement(s) not listed above
If you take supplements, which brand(s) are they?
WOULD YOU LIKE TO:

have more energybe stronger/build muscle masshave more enduranceincrease your sex drivebe thinnerbe more tonedimprove your complexionhave stronger nailshave healthier hairbe less moodybe less depressedbe less indecisivefeel more motivatedbe more organizedthink more clearlybe more focusedimprove memorydo better on testsnot be dependent on over-the-counter medication like aspirin, ibuprofen, antihistamines, sleeping aids, antacids, etc.)Stop using laxatives or stool softenerbe free of painsleep betterhave more agreeable breathhave more agreeable body odorhave stronger teethget less colds/flusget less allergiesreduce your risk of inherited tendencies (cancer, heart disease, diabetes, etc.)
Regional Health Center is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:*

I agree to receive other communications from Regional Health Center. In order to provide you the content requested, we need to store and process your personal data. If you consent to us storing your personal data for this purpose, please tick the checkbox below.I agree to allow Regional Health Center to store and process my personal data. You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.
Should be Empty:

RHC Health History Intake

Patient Information