Intake Form

Intake Form
Deneen Natural Health - Dr. Shana Deneen 5319 S. Lewis. Suite 200, Tulsa, OK 74105 (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):
City:
State:
Address:
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?
Primary Care Physician (PCP):
Emergency Name / Contact Number:
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
MUSCULOSKELETAL
MALE REPRODUCTIVE
Type of STD and date diagnosed
Date of last prostate exam

MonthDayYear
Date
Female Reproductive
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
Respiratory
Gastrointestinal
Cardiovascular
Nervous System
Immune / Blood
Cancer
Type & date
Endocrine
Mental / Emotional
Urinary
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:
Alcohol
Frequency of Alcohol:
Recreational Drugs
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?
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?
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 or acupuncturist before?
What modalities are you open to trying (place a “?” if you don’t know)
I attest the above information is true and accurate to the best of my knowledge.

Signature: ___________________________________ Date:
Signature:
Date:

MonthDayYear
Date
Should be Empty:

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