Intake Form

Intake Form
Deneen Natural Health - Dr. Shana Deneen 4157 S. Harvard Ave. Suite 111, Tulsa, OK 74135 (918) 884-6005 ~ https://www.deneennaturalhealth.com
Name:
Birth Date:

MonthDayYear
Date
What name do your prefer to be called?
If you are under 18, what are your guardian's name(s):
Address:
City:
State:
Zip Code:
Phone:
Alternate phone:
Email address:
example@example.com
How do you prefer us to contact you?
Is it okay to leave a message on your phone?
Is it okay to send an email?
example@example.com
Can I add you to my monthly email newsletter with health information and recipes?
Emergency Name / Contact Number:
Primary Care Physician (PCP):
When is the last time you saw your PCP?
Other Health Care Providers:
How did you hear about us?
Health History

For what concerns are you presenting here:
1.
2.
3.
Other Current Medical Diagnosis
Past Surgeries and Traumatic Injuries
Allergies & Intolerances
Allergies & Intolerances
Family Medical History:
Mother:
Maternal Grandparents:
Father:
Paternal Grandparents:
Siblings:
What is your family heritage?
Review of Systems
HEAD
Headaches / MigrainesVisual DisorderWatery, itchy or dry eyesSensitivity to lightSinus problemsDental problemsHearing lossRinging in the earsEaracheLight-headed / dizzy
MUSCULOSKELETAL
Back painCarpal Tunnel SyndromeGoutOsteoporosisJoint pain or stiffnessArthritis
MALE REPRODUCTIVE
Enlarged prostateSexually activeDecreased sex driveInfertilitySTD
Type of STD and date diagnosed
Date of last prostate exam

MonthDayYear
Date
Female Reproductive
Menstrual irregularitiesEndometriosisFibrocystic breastsFibroids / Ovarian cystsPCOSPremenstrual syndromeMenopausal symptomsBreast cancerVaginal infectionsDecreased sex driveUrinary tract infectionSTD
Type of STD and date diagnosed
Date of last menstrual cycle

MonthDayYear
Date
Length of Cycle
Interval of Times Between Cycles
Date of last GYN Exam

MonthDayYear
Date
PAP + / - Date
Sexually Active
Birth Control
Number of Children
Number of Pregnancies
Are you pregnant
Age of First Period
List any PMS symptoms (e.g. heavy / scanty flow, clots, cramp, breast tenderness, bloating, mood changes, other)
SKIN
Type a question

AcneItchingRashes, cysts or wartsEasy bruisingSwelling / edemaEczema / PsoriasisDry skinVaricose veinsHair loss / changed textureNail changes
Respiratory
Asthma, bronchitisHoarsenessEmphysemaTuberculosisShortness of breathChronic cough
Gastrointestinal
Reflex / UlcersSore throat / Difficulty swallowingInflammatory Bowel DisorderHepatitisGallbladder diseaseConstipationAbdominal painDiarrheaNausea / VomitingGas / Bloating
Cardiovascular
High blood pressureElevated cholesterolHeart diseaseArrhythmia / Murmur / PalpitationsChest painHeart attackStroke
Nervous System
DementiaSeizuresPoor concentration / MemoryNeuropathy / ParalysisMultiple SclerosisRestless Legs
Immune / Blood
Clotting disorderChronic infectionSlow wound healingHIV / AIDSAnemia
Cancer
Type & date
Endocrine
Chronic fatigueDiabetesThyroid disorderWeight loss / gainChange in thirst / appetiteOverly cold / hot
Mental / Emotional
DepressionAnxietyAnger managementGriefDrug addictionEating disorderLearning disorderAlcoholismADD / ADHD
Urinary
Kidney / Bladder diseaseIncontinenceFrequent or painful urinationKidney stones
OTHER
Medications and Supplements

Current medications, supplements and herbal medicines (write on back, if necessary). Include any medication you take for pain, as well
Please list they type of medication / supplement, what it is used for, the date you started and the dosage / frequancy.
Tobacco:

Never usedUsed but quit
Alcohol

Never usedCurrently using
Frequency of Alcohol:
Recreational Drugs

Never usedUsed but quitCurrently using
Are you currently having thoughts of harming yourself or others?
Lifestyle
Occupational Status:
What do you love to do?
Please list your spiritual orientation or religion?
What is your marital status?

SingleMarriedSeparated / DivorcedSignificant partner (not legally married)WidowedOther
Do you cook for yourself or family?
How many times do you eat each day?
How many hours do you sleep?
Do you have difficulty?

Falling asleepStaying asleepWaking earlyWaking refreshed
What have you eaten and drank in the past 24 hours (or on a typical day)?
Are there any foods you avoid?
What type of regular movement do you engage in?
How would you rate the level of stress in your life (0 10, 10 highest)?
How do you rate your ability to manage your stress (0 10, 10 best)?
How do you rate your energy level (0 10, 10 best)?
What healthy habits do you already engage in?
What are your long term goals in regards to your overall health and working with this Clinic?
Have you ever worked with a naturopathic doctor before?
What modalities are you open to trying (place a “?” if you don’t know)

NutritionSupplementsBotanical / Herbal MedicineAcupunctureHydrotherapyHomeopathyLab WorkLifestyle / Movement
I attest the above information is true and accurate to the best of my knowledge.

Signature: ___________________________________ Date:
Signature:

Clear
Date:

MonthDayYear
Date
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Intake Form

Health History

Family Medical History:

Review of Systems

HEAD

MUSCULOSKELETAL

MALE REPRODUCTIVE

Female Reproductive

SKIN

Respiratory

Gastrointestinal

Cardiovascular

Nervous System

Immune / Blood

Cancer

Endocrine

Mental / Emotional

Urinary

OTHER

Medications and Supplements

Lifestyle