New Patient Adult Intake form

New Patient Adult Intake form
Legal Name

First NameLast Name
Drivers License or ID #
Emergency Contact Name: First Name Last Name Phone Number: Phone Number Relationship:
Nick Name/ Preferred Name (if different form Legal Name)
Email
example@example.com
How did you find us?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
DOB

MonthDayYear
Date
Sex Assigned at Birth
Current Gender Identity
Preferred Pronouns
Current Height & Weight
Health Concerns & Goals
Please describe any health concerns, including date of onset, severity, and frequency.
Goals for yourself
Describe yourself
Past Medical Problems
Please list past medical problems
Please describe any past or current disabilities
Please describe your health as a child including any illnesses and birth injuries if applicable
Were you born via C- Section or Vaginal Delivery?
Past Surgeries- including date of and any continuing problems?
Medications & Allergies
Any Allergies to medications, foods, environmental?
Please list all medications you currently take including over the counter and the reason:
Please list all herbs/ supplements/ vitamins you currently take:
Experience with alternative/ complementary/ functional/ integrative medicine?
Family History
Are you adopted?
Please indicate if your immediate family has a history of the following: (include only blood relatives- parents, grandparents, siblings, and children)

I am adopted and do not know biological family historyFamily History UnknownAlcohol AbuseAnemiaAnesthetic ComplicationArthritisAsthmaBladder ProblemsBleeding DiseaseBreast CancerColon CancerDepressionDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolKidney DiseaseLeukemiaLung/Respiratory DiseaseMigrainesOsteoporosisOther CancerRectal CancerSeizures/ConvulsionsSevere AllergyStroke/CVA of the BrainThyroid ProblemsMother, Grandmother, or Sister developed heart disease before the age of 65Father, Grandfather, or Brother developed heart disease before the age of 55Other
Other relevant family history
Lifestyle Concerns
Do you have any pain? Location? What makes it better? Worse? Date it started?
When is your energy highest?
When is your energy lowest?
Sleep Pattern
Time to bed
Time you wake up
How long does it typically take you to fall asleep?
How many hours do you sleep per night?
What happens at night/ details about your sleep patterns
Do you wake up throughout the night?
Do you nap? How long? How often?
Any recent changes in sleep patterns?
Do you dream?
Do you remember your dreams?
Any Recurring Dreams?
Nutrition History
Any particular Diet?
Eating Habits
Body Image
Any history or ongoing problem of anorexia/bulimia/ other?
Current Weight & Height
Weight 5 years a go
Weight at 21, if applicable
Any recent weight changes?
Who prepares your food?
Do you eat alone?
Do you eat while standing or driving?
Do you eat organics?
Any frequent cravings?
Food dislikes?
Favorite Foods?
Do you frequently eat out?
Do you eat fast food?
Substance Use
Do you drink alcohol? how many drinks per day or week?
Do you use Tobacco? How often? # of years?
Caffeine?
Other
What do you eat & drink on a typical day?
Social History
Who do you live with?
How is your home life?
Marital history
Most positive/ significant relationships
Most negative relationships
Community?
Would you consider yourself religious &/or spiritual?
Financial Hardships?
What does a typical day/ week for you look like?
How many hours do you spend per week working?
Would you like to increase or decrease?
How many hours do you spend per week child rearing?
Would you like to increase or decrease?
How many hours do you spend per week on school?
Would you like to increase or decrease?
How many hours do you spend per week exercising?
Would you like to increase or decrease?
How many hours do you spend per week watching TV or playing video games?
Would you like to increase or decrease?
Hours per week on phone?
Would you like to increase or decrease?
Current Employer, if applicable
Past work history
Birthplace
Where have you lived and for how long?
Hobbies/ Interests
Do you read? If so, what? (newspaper, books, magazines?)
Volunteer work?
Do you have any history of mental/ physical abuse?
Rate your stress level on a scale of 1(very low/ none) -10 (extremely high)
What do you do to relax?
What are your supports?
What have you tried to help manage stress?
Do you have depression?
Important Stressful anniversaries-births/deaths/ accident/ losses
Traumas that have affected you
Do you have PTSD?
Preventative Health
Do you exercise?
Any specific exercise program?
History of exercise?
Sun Exposure/ Hours per day?
Do you wear sunscreen? What type/brand?
Do you feel safe?
Recent labs? Please fax to 512-309-5437 or bring to your appointment (not required but recommended)
Immunization History?
Insurance information
Insurance Information (if applicable) Name of Insurance company & plan
Group #Member ID
Secondary Insurance Information (if applicable) Name of Insurance company & plan Member ID Group #
Should be Empty:

New Patient Adult Intake form

Health Concerns & Goals

Past Medical Problems

Medications & Allergies

Family History

Lifestyle Concerns

Sleep Pattern

Nutrition History

Substance Use

Social History

Preventative Health

Insurance information