Patient Intake Form
Email
example@example.com
Today's Date
/
Month
/
Day
Year
Date
Name
First Name
Last Name
Preferred Name, if different than above
Please choose your preferred pronoun
Her
Him
Them
Zim
Hir
Birth Gender
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
Phone number
10-digit
Social Security Number
*
Address
Address 1
Address 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Genetic Background
African American
Hispanic
Mediterranean
Asian
Native American
Caucasian
Northern European
Other
How did you hear about our practice?
Wellness Recovery website
Institute for Functional Medicine
Referral from doctor
Referral from friend/family
Social media
Google
Facebook
Wellness Recovery patient
Other
Patient Name (We have a referral bonus program)
First Name
Last Name
Doctor name
First Name
Last Name
Do you have insurance?
*
Yes
No
Who is your insurance carrier?
*
Do you have Medicaid?
*
Yes
No
Do you have Medicare?
*
Yes
No
We need picture of your face for our medical records. Please choose an option
I have a picture I would like to upload
I would like to take a picture now with my device
Please upload a picture of your face
Upload picture from file
Take a picture
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Substance Use History
Have you ever been treated for substance use disorder or addiction in the past?
*
Yes
No
Name of Previous Clinic
*
Dates of Previous Treatment
*
Reason for leaving
*
Please describe why you left the previous clinic.
Were you prescribed buprenorphine? (Suboxone®, Zubsolv®, Subutex®, Bunavail®, etc.)
*
Yes
No
I was prescribed
dose
*
mg per day.
If no, have you ever used buprenorphine off the street?
*
Yes
No
Have you ever used inhaled or IV recreational drugs
*
Yes
No
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Allergies
Please list the Name of Medication/Supplement/Food and the Reaction
Do you have any allergies to medications, foods, or supplements?
Yes
No
If yes, please list allergies
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Lifestyle Review
Sleep
How many hours of sleep do you get each night on average?
Please select
less than 5 hours
5 hours
5.5 hours
6 hours
6.5 hours
7 hours
7.5 hours
8 hours
8.5 hours
9 hours
9.5 hours
10 hours
greater than 10 hours
Sleep
Yes or No
Do you have problems falling asleep?
Yes
No
Do you have problems staying asleep?
Yes
No
Do you have problems with insomnia
?
Yes
No
Do you feel rested upon awakening?
Yes
No
Do you have trouble waking up in the morning?
Yes
No
Do you snore?
Yes
No
Are your sleep habits routine?
Yes
No
Describe how you fall asleep?
Do you use sleeping aids?
Yes
No
Please explain sleeping aid use
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Lifestyle Review
Nutrition
Are there any foods that you crave or binge on?
Yes
No
If yes, list foods:
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Lifestyle review
Smoking
Do you smoke?
Yes
Previous smoker, but not currently
No
If current smoker, please complete
Have you attempted to quit?
Yes
No
If yes, using what methods?
If previous smoker, please complete
Are you regularly exposed to second-hand smoke?
Yes
No
Lifestyle Review
Alcohol
Have you ever had a problem with alcohol?
Yes
No
Details regarding alcohol problem:
Lifestyle Review
Stress
What are your hobbies or leisure activities?
Have you ever been abused, a victim of crime, or experienced a significant trauma?
Yes
No
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Lifestyle Review
Relationships
Marital Status (check all that apply)
Single
Married
Divorced
Gay/Lesbian
Long-term Partner
Widow/er
With whom do you live? (include children, parents, relatives, friends, pets)
Current occupation
Who are the most important people in your life?
Please check all of your resources for emotional support: (check all that apply)
Spouse/Partner
Family
Friends
Religious/Spiritual
Pets
None
Other
Do you have a religious or spiritual practice
Yes
No
If yes, what kind?
Describe your present relationship:
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Women's History
Obstetric History
Are you fertile? (Do you still have the ability to have children?)
Yes
No
What form of contraception/birth control do you use / plan to use?
List Birth Control
Are you currently pregnant?
Yes
No
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If Skin 'Other' - please describe:
Cardiovascular
Current
Past
Never
Angina
Heart attack
Heart failure
Hypertension (high blood pressure)
Stroke
High blood fats (cholesterol, triglycerides)
Rheumatic fever
Arrythmia (irregular heart rate)
Murmur
Mitral valve prolapse
Other
If Cardiovascular 'Other' - please describe:
Neurologic / Emotional
Current
Past
Never
Epilepsy / Seizures
ADD / ADHD
Headaches
Migraines
Depression
Anxiety
Autism
Multiple sclerosis
Murmur
Mitral valve prolapse
Other
Cancer
Current
Past
Never
Lung
Breast
Colon
Prostate
Skin
Other
If Cancer 'Other' - please describe:
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History
Medical History (continued)
Medical History - Diagnostic Studies
Medical History - Injuries
Medical History - Surgeries
Hospitalizations
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Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months
General
Mild
Moderate
Severe
Cold hands and feet
Cold Intolerance
Daytime sleepiness
Difficulty falling asleep
Early waking
Fatigue
Fever
Flushing
Heat intolerance
Night waking
Nightmares
Can't remember dreams
Low body temperature
Head, Eyes, and Ears
Mild
Moderate
Severe
Conjuctivitis
Distorted sense of smell
Distorted taste
Ear fullness
Ear ringing/buzzing
Eye crusting
Eye pain
Eyelid margin redness
Headache
Hearing loss
Hearing problems
Migraine
Sensitivity to loud noises
Vision problems
Musculoskeletal
Mild
Moderate
Severe
Back muscle spasm
Calf cramps
Chest tightness
Foot cramps
Joint deformity
Joint pain
Joint redness
Joint stiffness
Muscle pain
Muscle spasms
Muscle stiffness
Muscle twitches:
----Around eyes
----Arms or legs
Muscle weakness
Neck muscle spasm
Tendonitis
Tension Headache
TMJ problems
Mood / Nerves
Mild
Moderate
Severe
Agoraphobia
Anxiety
Auditory hallucinations
Blackouts
Depression
Difficulty:
----Concentrating
----With balance
----With thinking
----With judgement
----With speech
----With memory
Dizziness (spinning)
Fainting
Fearfulness
Irritability
Light-headedness
Numbness
Other phobias
Panic attacks
Paranoia
Seizures
Suicidal thoughts
Tingling
Tremor/trembling
Visual hallucinations
Cardiovascular
Mild
Moderate
Severe
Angina / chest pain
Breathlessness
Heart attack
Heart murmur
High blood pressure
Irregular pulse
Mitral valve prolapse
Palpitations
Phlebitis
Swollen ankles/feet
Varicose veins
Urinary
Mild
Moderate
Severe
Bed wetting
Hesitancy
Infection
Kidney disease
Kidney stone
Leaking/incontinence
Pain/burning
Prostate enlargement
Prostate infection
Urgency
Digestion
Mild
Moderate
Severe
Anal spasms
Bad teeth
Bleeding gums
Bloating of:
----Lower abdomen
----Whole abdomen
----Bloating after meals
Blood in stools
Burping
Canker sores
Cold sores
Constipation
Cracking at corner of lips
Dentures w/poor chewing
Diarrhea
Difficulty swallowing
Dry mouth
Flatulence (passing gas)
Fissures
Foods "repeat" (reflux)
Heartburn
Hemorrhoids
Intolerance to:
----Lactose
----All dairy products
----Gluten (wheat)
----Corn
----Eggs
----Fatty foods
----Yeast
Liver disease/jaundice
(yellow eyes or skin)
Lower abdominal pain
Mucus in stools
Nausea
Periodontal disease
Sore tongue
Strong stool odor
Undigested food in stools
Upper abdominal pain
Vomiting
Eating
Mild
Moderate
Severe
Binge eating
Bulimia
Can't gain weight
Can't lose weight
Carbohydrate craving
Carbohydrate intolerance
Poor appetite
Salt cravings
Frequent dieting
Sweet cravings
Caffeine dependency
Respiratory
Mild
Moderate
Severe
Bad breath
Bad odor in nose
Cough - dry
Cough - productive
Hayfever:
----Spring
----Summer
----Fall
----Change of season
Hoarseness
Nasal stuffiness
Nose bleeds
Post nasal drip
Sinus fullness
Sinus infection
Snoring
Sore throat
Wheezing
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Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months
Nails
Mild
Moderate
Severe
Bitten
Brittle
Curve up
Frayed
Fungus - fingers
Fungus - toes
Pitting
Ragged cuticles
Ridges
Soft
Thickening of:
----Finger nails
----Toenails
White spots/lines
Lymph Nodes
Mild
Moderate
Severe
Enlarged/neck
Tender/neck
Other enlarged/tender
lymph nodes
Skin, Dryness of
Mild
Moderate
Severe
Eyes
Feet
----Any cracking?
----Any peeling?
Hair
----And unmanageable?
Hands
----Any cracking?
----Any peeling?
Mouth/throat
Scalp
----Any dandruff?
Skin in general
Skin Problems
Mild
Moderate
Severe
Acne on back
Acne on chest
Acne on face
Acne on shoulders
Acne on scalp
Athlete's foot
Bumps on back
of upper arms
Cellulite
Dark circles under eyes
Ears get red
Easy bruising
Eczema
Herpes - genital
Hives
Jock itch
Lackluster skin
Moles w color/size change
Oily skin
Pale skin
Patchy dullness
Psoriasis
Rash
Red face
Sensitive to bites
Sensitive to poison ivy/oak
Shingles
Skin cancer
Skin darkening
Strong body odor
Thick calluses
Vitiligo
Itching Skin
Mild
Moderate
Severe
Anus
Arms
Ear canals
Eyes
Feet
Hands
Legs
Nipples
Nose
Genitals
Roof of mouth
Scalp
Skin in general
Throat
Male Reproductive
Mild
Moderate
Severe
Discharge from penis
Ejaculation problem
Genital pain
Impotence
Infection
Lumps in testicles
Poor libido (low sex drive)
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Medications / Supplements
Current medications (include prescription & over-the-counter)
Current supplements (vitamins/minerals/herbs etc.)
Have medications or supplements ever caused unusual side effects or problems?
Yes
No
If yes, describe:
Have you used any of these regularly or for a long time?
Regularly or long time?
NSAIDs (Advil, Motrin,
Aleve, etc.) or Aspirin
Yes
No
Tylenol (acetaminophen)
Yes
No
Acid-blocking drugs
(Zantac, Prilosec, Nexium, etc.)?
Yes
No
How many times have you taken antibiotics?
Have you ever taken long-term antibiotics?
Yes
No
If yes, explain:
How often have you taken oral steroids (e.g. cortisone, prednisone, etc.)?
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Readiness Assessment
In order to improve your health, how willing are you to:
Significantly modify your diet
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Take several nutritional supplements each day
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Keep a record of everything you eat each day
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Modify your lifestyle (e.g., work demands, sleep habits)
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Practice a relaxation technique
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Engage in regular exercise
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
How confident are you of your ability to organize and follow through on the above health-related activities?
1
2
3
4
5
Not confident at all
Very confident
1 is Not confident at all, 5 is Very confident
If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to follow through?
At the present time, how supportive do you think the people in your household will be to your implementing the above changes?
1
2
3
4
5
Very unsupportive
Very supportive
1 is Very unsupportive, 5 is Very supportive
How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful to you as you implement your personal health program?
1
2
3
4
5
Very infrequent contact
Very frequent contact
1 is Very infrequent contact, 5 is Very frequent contact
Any additional comments about your readiness
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Health Goals / Health Beliefs
What do you hope to achieve in your visit with us?
Would you like to discuss the religious or spiritual implications of your healthcare?
Yes
No
Do your religious or spiritual beliefs impact your treatment decisions?
Yes
No
When was the last time you felt well?
Did something trigger your change in health?
What makes you feel better?
What makes you feel worse?
How does your condition affect you?
What do you think is happening and why?
What do you feel needs to happen for you to get better?
In what ways do you intend to participate in increasing your healthcare?
What do you believe is your role in treating your illness?
Submit
Should be Empty: