Tao Vitality New Patient Intake Form

This is a confidential record of your medical history and will be kept in this office. Information contained in it will not be released to any person unless authorized by you.
Date 00/00/0000*
Full Name: First Middle Last*
Date of Birth*
Address
City
State
Zip Code
E-mail*
example@example.com
Home Phone Number
Home Phone
Work Phone Number
Work Phone
Mobile Phone Number
Mobile Phone
Gender*

MaleFemale
Employed By/Occupation*
Marital Status*
Number of Children*
What contact number do you prefer we use?*
May we leave a message?*
Emergency Contact/Phone Number/Relationship*
Name of Medical Doctor*
Phone Number*
How did you hear about us?

Friend(s)FamilyPresentationGoogleSocial NetworkOther
Insurance (Primary)
ID#
Health Concerns
What are your main health concerns in order of importance to you?
What forms of treatment have you used in the past to treat this condition?
Vitamins and Supplements
Please list all vitamin/mineral/herbal supplements you are currently taking: Supplement (Including Brand) Dosage/ When did you begin this supplement?
Medications
Please list all prescription and non-prescription medications you are currently taking: Medication/ Dosage/When did you begin this medication?
Please list all prescription medications you have taken in the past for longer than six months. Indicate how long you took each medication.
Family History
Next to each individual listed below, please put an “L” for living or “D” for deceased, as well as present age or age at the time of death. Please indicate if the family member suffered from any diseases such as cancer, high blood pressure, heart attack, stroke, diabetes, skin disorders or other.
Mother L/D-Age-Diseases Suffered-Cause of Death
Father L/D-Age-Diseases Suffered-Cause of Death
Maternal Grandmother L/D-Age-Diseases Suffered-Cause of Death
Maternal Grandfather L/D-Age-Diseases Suffered-Cause of Death
Paternal Grandmother L/D-Age-Diseases Suffered-Cause of Death
Paternal Grandfather L/D-Age-Diseases Suffered-Cause of Death
Sisters L/D-Age-Diseases Suffered-Cause of Death
Bothers L/D-Age-Diseases Suffered-Cause of Death
Maternal Aunts L/D-Age-Diseases Suffered-Cause of Death
Paternal Aunts L/D-Age-Diseases Suffered-Cause of Death
Maternal Uncles L/D-Age-Diseases Suffered-Cause of Death
Paternal Uncles L/D-Age-Diseases Suffered-Cause of Death
Medical History
Please list any injuries and/or major surgery you have had and when they occurred.
Please list any major illnesses or diseases that you have or have had.
Vaccinations
Vaccinations (please check)

DPT (Diphtheria, Pertussis and Tetanus)Flu ShotMMR (Measles, Mumps, and Rubella)HepatitisChicken PoxPolioHPVOtherNonePfizer Covid-19Moderna Covid-19Johnson & Johnson's Covid-19
Please list other vaccinations
Did you experience any adverse effects from any vaccination? If yes, please explain.
Symtoms
Please check off any of the following symptoms that you currently having or have had in the past.
General

Fatigue-CurrentFatigue-PastChange in appetite-CurrentChange in appetite-PastChange in thirst-CurrentChange in thirst-PastCravings-CurrentCravings-PastWeight gain-CurrentWeight gain-PastPoor sleep-CurrentPoor sleep-PastChills or fever-CurrentChills or fever-PastNight sweats-CurrentNight sweats-PastSweat easily-CurrentSweat easily-PastAllergies-CurrentAllergies-PastCancer-CurrentCancer-PastDiabetes-CurrentDiabetes-Past
Gastrointestinal

Nausea-CurrentNausea-PastVomiting-CurrentVomiting-PastVomiting blood-CurrentVomiting blood-PastReflux or heartburn-CurrentReflux or heartburn-PastConstant hunger-CurrentConstant hunger-PastUlcer-CurrentUlcer-PastIndigestion-CurrentIndigestion-PastAbdominal pain or cramping-CurrentAbdominal pain or cramping-PastBloating-CurrentBloating-PastGall Stones-CurrentGall Stones-PastLiver disease-CurrentLiver disease-PastJaundice-CurrentJaundice-PastIntestinal parasites-CurrentIntestinal parasites-PastGas-CurrentGas-PastConstipation-CurrentConstipation-PastDiarrhea-CurrentDiarrhea-PastChronic laxative use-CurrentChronic laxative use-PastRectal burning/pain-CurrentRectal burning/pain-PastHemorrhoids-CurrentHemorrhoids-PastBlood in stool-CurrentBlood in stool-Past
Eyes Ears Nose & Throat

Eye pain-CurrentEye pain-PastEye strain-CurrentEye strain-PastBlurry vision-CurrentBlurry vision-PastImpaired vision-CurrentImpaired vision-PastCataracts-CurrentCataracts-PastEar aches-CurrentEar aches-PastEar infections-PastEar infections-CurrentRinging in ears-CurrentRinging in ears-PastVertigo/Dizziness-CurrentVertigo/Dizziness-PastSinus infections-CurrentSinus infections-PastNasal obstruction-CurrentNasal obstruction-PastLoss of smell/taste-CurrentLoss of smell/taste-PastMercury fillings-CurrentMercury fillings-PastJaw pain or clicks-CurrentJaw pain or clicks-PastTonsillitis-CurrentTonsillitis-PastSores in mouth-CurrentSores in mouth-PastRecurrent sore throat-CurrentRecurrent sore throat-PastEnlarged glands-CurrentEnlarged glands-PastEnlarged thyroid-CurrentEnlarged thyroid-PastFacial pain/tics-CurrentFacial pain/tics-PastHeadaches-CurrentHeadaches-Past
Respiratory

Difficulty breathing-CurrentDifficulty breathing-PastShortness of breath-CurrentShortness of breath-PastChronic cough-CurrentChronic cough-PastBronchitis-CurrentBronchitis-PastEmphysema-CurrentEmphysema-PastAsthma-CurrentAsthma-PastWheezing-CurrentWheezing-PastCoughing blood-CurrentCoughing blood-PastPhlegm in throat-CurrentPhlegm in throat-Past
Neurological

Anxiety-CurrentAnxiety-PastDepression-PastDepression-CurrentIrritability-CurrentIrritability-PastEmotional problems-CurrentEmotional problems-PastLoss of balance-PastLoss of balance-CurrentPoor memory-CurrentPoor memory-PastMisspeaking-CurrentMisspeaking-PastDizziness-CurrentDizziness-PastExtremity numbness-CurrentExtremity numbness-PastExtremity tingling-CurrentExtremity tingling-PastParalysis-CurrentParalysis-PastSeizures/Epilepsy-CurrentSeizures/Epilepsy-PastConcussion-CurrentConcussion-PastLack of coordination-CurrentLack of coordination-PastRestless leg syndrome-CurrentRestless leg syndrome-PastOption31
Cardiovascular

Chest pain-CurrentChest pain-PastPalpitations-CurrentPalpitations-PastHigh blood pressure-CurrentHigh blood pressure-PastLow blood pressure-CurrentLow blood pressure-PastHeart attack-CurrentHeart attack-PastCongestive heart failure-CurrentCongestive heart failure-PastIrregular heartbeat-CurrentIrregular heartbeat-PastPacemaker-CurrentPacemaker-PastArtificial heart valve-CurrentArtificial heart valve-PastStroke-CurrentStroke-PastFainting-CurrentFainting-PastVaricose veins-CurrentVaricose veins-PastDeep leg pain-CurrentDeep leg pain-PastCold hands or feet-CurrentCold hands or feet-PastAnemia-CurrentAnemia-PastEasy Bruising-CurrentEasy Bruising-PastSwelling of limbs-CurrentSwelling of limbs-Past
Skin and Hair

Skin and Hair-CurrentSkin and Hair-PastDryness-CurrentDryness-PastRash-CurrentRash-PastSpider veins-CurrentSpider veins-PastStretch marks-CurrentStretch marks-PastItching-CurrentItching-PastEczema-CurrentEczema-PastPsoriasis-CurrentPsoriasis-PastAcne-CurrentAcne-PastRecent moles-CurrentRecent moles-PastHives or allergic reactions-CurrentHives or allergic reactions-PastDandruff-CurrentDandruff-PastLoss of hair-CurrentLoss of hair-PastThinning hair-CurrentThinning hair-PastTick/Flea bite/Spider bites-CurrentTick/Flea bite/Spider bites-PastOther Skin Problems-CurrentOther Skin Problems-Past
Infections

Strep throat-CurrentStrep throat-PastMononucleosis-CurrentMononucleosis-PastTuberculosis-CurrentTuberculosis-PastHepatitis-CurrentHepatitis-PastHerpes (HSV)-CurrentHerpes (HSV)-PastLyme Disease-CurrentLyme Disease-PastBabesia-CurrentBabesia-PastBartonella-CurrentBartonella-PastCovid-19- CurrentCovid-19- Past
Muscle, Bone & Joints

Neck pain-CurrentNeck pain-PastBack pain-CurrentBack pain-PastArthritis-CurrentArthritis-PastBursitis-CurrentBursitis-PastJoint pain or stiffness-CurrentJoint pain or stiffness-PastArtificial joint-CurrentArtificial joint-Muscle pain-CurrentMuscle pain-PastMuscle weakness-CurrentMuscle weakness-Past
Urinary

Frequent urination-CurrentFrequent urination-PastUrgency to urinate-CurrentUrgency to urinate-PastIncontinence-CurrentIncontinence-PastPain on urination-CurrentPain on urination-PastWaking at night to urinate-CurrentWaking at night to urinate-PastUrinary tract infection-CurrentUrinary tract infection-PastBlood in urine-CurrentBlood in urine-PastKidney stones-CurrentBlood in urine-PastMale reproductive-CurrentMale reproductive-Past
Female Reproductive

Irregular periods-CurrentIrregular periods-PastHeavy periods-CurrentHeavy periods-PastLight Periods-CurrentLight Periods-PastClots-CurrentClots-PastToo short/Too strong-CurrentToo short/Too strong-PastPainful periods-CurrentPainful periods-PastPMS-CurrentPMS-PastSore breast with menses-CurrentSore breast with menses-PastSexually transmitted disease-CurrentSexually transmitted disease-PastInfertility-CurrentInfertility-PastHPV-CurrentHPV-PastVaginal sores-CurrentVaginal sores-PastVaginal discharge-CurrentVaginal discharge-Past
Menopausal

YesNo
Breasts

LumpsTendernessNipple discharge
Do you do breast self-exams?

YesNo
Pregnant?

YesNo
Trying to conceive?

YesNo
Do you practice birth control?

YesNo
What type of birth control?
Number of Pregnancies?
Number of Births?
Number of Miscarriages?
Number of Abortions?
Male Reproductive

Prostate problem-CurrentProstate problem-PastImpotence-CurrentImpotence-PastSexually transmitted disease-CurrentSexually transmitted disease-PastSores on genitals-CurrentSores on genitals-PastDischarge-CurrentDischarge-PastTesticular mass-CurrentTesticular mass-PastTesticular pain-CurrentTesticular pain-PastInfertility/Low sperm count-CurrentInfertility/Low sperm count-PastHernia-CurrentHernia-Past
Personal Habits and Lifestyle
How many cups/bottles/glasses do you drink on average per day?
Water
Coffee
Tea
Herbal Tea
2% Milk
Skim Milk
Fruit Juice
Soft Drinks (Regular)
Soft Drinks (Diet)
Beer
Wine
Liquor
Other
Please check the source of your drinking water.
Do you smoke?

YesNo
If yes, how many per day?
Do you use recreational drugs?

YesNo
How frequently do you move your bowels? Per day or per week?
How many hours of sleep do you get on average?
What time do you go to sleep?
What time do you wake?
Do you feel refreshed in the morning?

YesNo
How many hours do you work each day?
Do you often feel overworked?

YesNo
Do you exercise?

YesNo
If yes, how often?
What do you do for exercise? (Indicate activity, frequency, intensity and duration)
What was the most stressful event in your life?
Do you think it still affects you today?

YesNo
Rate your stress level from 1-10 (1 being lowest, 10 being highest)

109876543210
What methods do you use to manage your stress?
Known Environmental Allergies
Known Environmental Sensitivities
Eating Habits
Diet

Non-VegetarianVegetarianVegan
Known Food Allergies
Known Food Intolerances
Please send us any related documents.

Cancelof
After you click Submit you will be taken to a Thank You page and asked to download a Diet Diary to bring with you on your first visit. Please fill out the Diet Diary completly for one week.

If you aren't redirected to the Thank You page the form was not submitted.

If you make any mistakes an error message will appear at the bottom of this page in red.
Should be Empty: