New Patient Intake forms

New Patient Intake

All information provided is confidential and protected under HIPAA standards
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Date of Birth

YearMonthDay
Date
Gender
Place of Birth
City/State or Town/Country if not in the US
Marital Status
Drug or Food Allergies with symptoms:
Example: Peanuts - Hives/difficulty breathing, strawberries - itchy tongue
CaucasianAfrican AmericanHispanicAsianMediterraneanNative AmericanOther
GED or High SchoolUnder-graduatePost-graduateSome CollegeOther
Occupation/Job Title
Please list your top health concerns: (example - back pain, anxiety, diarrhea, Fatigue, etc.)
Please list your wellness goals:
(Things you want to have improved - more energy to ... be able to perform ... have less ____ pain )
Please list activities you enjoy or hobbies
ex: watching movies, hiking, biking, reading, puzzles, dancing, painting, crafting, sewing, building, media editing, etc.
Did something trigger your change in health? (Stressful events - Loss of relationship or loved one, moving, financial changes)
How motivated are you to make changes to your health? (0-10, 10 being the most)
How would you rate your stress level overall for past 2 weeks and what is causing the most stress? (0-10, 10 being the most)
Example: 4-5, Back pain and work
Sleep Habits: (Average number of hours slept per day, continuous sleep or interrupted, daysleeper/nightsleeper, waking rested?)
Example: 9hrs, interrupted, daysleeper, not waking rested OR 4hrs continuous, nightsleeper, waking rested, etc.
Please list all current Medications:
Format example: None OR Bupropion 10mg tablet 2x a day for depression, Lisinopril 5mg 2x a day for high blood pressure
Please list all current Supplements:
Format example: None OR Company/Brand, Name of supplement, 2 tablets 3 times a day

Past Medication history

Rows	Past use	Rarely used	Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Opiods (Oxycodone, Hydrocodone, Vicodin)
Oral/Injected Steroids (Cortisone, Dexamethasone, Prednisone)
Oral contraceptives

Digestive Medical History

Rows	Past condition	Ongoing condition	N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Appendicitis

Respiratory Medical History

Rows	Past condition	Ongoing condition	N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Cough
Shortness of breath
Wheezing
Frequent infections
Nasal congestion
Other

Cardiovascular Medical history

Rows	Past condition	Ongoing condition	N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Heart Murmur
Other

Skin Medical History

Rows	Past condition	Ongoing condition	N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other

Pelvic Medical History

Rows	Past conditon	Ongoing condition	N/A
Kidney stones
Gout
Interstitial cystitis
Urinary tract infections
Candida/Yeast infections
Erectile dysfunction
Sexual dysfunction
Herpes - genital infection
Gonorrhea/Chlymidia - genital infection
Syphillis - genital infection
HIV/AIDS
Pyelonephritis (Kidney infection)
Painful urination
Blood in urine
Discharge in urine
Kidney Disease
Other

Endocrine (Hormone) Medical History

Rows	Past condition	Ongoing condition	N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other

AutoImmune Medical History

Rows	Past condition	Ongoing condition	N/A
Osteoarthritis
Fibromyalgia
Rheumatoid Arthritis
Lupus (SLE)
Polymyalgia Rhuematica
Scleroderma
Hashimoto's Thyroiditis
Multiple Sclerosis
Sjogren's
Myasthenia Gravis
PolyMyositis
Raynaud's

Mental Health History

Rows	Past condition	Ongoing condition	N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other

Cancer Medical History cont.

Rows	Past condition	Ongoing condition	N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Blood cancer
Bone Marrow cancer
Other cancer

Silver Mercury fillingGold fillingsRoot canalsImplantsTooth painBleeding gumsGingivitisFloss regularly

Fibrocystic breastsEndrometriosisFibroidsInfertilityPainful periodsHeavy PeriodsPMDDToxemiaGestational DiabetesPost-Partum DepressionComplications during ChildbirthMiscarriage/AbortionLive Birth
Hot flashesMood SwingsConcentration/Memory problemsVaginal drynessDecreased libidoHeadachesWeight gainLoss of control of urinePalpitationsDifficulty sleeping
Prostate enlargementProstate infectionChange in libidoImpotenceDifficulty obtaining an erectionDifficulty maintaining an erectionFrequent urination at nightUrgency/Hesitancy/change in streamLoss of urine control
Please mention any current or past alcohol dependence or substance dependances:
Please list any significant physical trauma you've experienced:
Please list emotional trauma you've experienced in your life:
Information here will not be shared

Family History

Rows	Mother	Father	Sibling	Children	Mat. Grandparent	Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease

Should be Empty:

Rows	Present use	Past use	Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy