Adult Intake Form

Patient Information
Today's Date*

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Sex/Gender
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Marital Status

SingleMarriedCommon-Law PartnerDivorcedSeparatedWidowedOther
Occupation
Referral
Referred by: (please check one box)

FriendDoctorClose to Home/WorkFamilyHospitalInsurance PlanInternetYellow Pages
Name of Family Physician
Phone Number of Family Physician
Please enter a valid phone number.
In Case of Emergency

We will contact the person below in case of an emergency.
Emergency Contact Person*

First NameLast Name
Relationship to Patient
Home Phone Number *
Please enter a valid phone number.
Work or Cell Phone Number*
Please enter a valid phone number.
Reproductive Health
Date of last mentstrual period

MonthDayYear
Date
Age of first menses
Number of Pregnancies
Number of Miscarriages or Abortions
Allergies
Do you have any allergies?
Health History
What is your main concern?
When did it start?
Did your illness start after an event, accident or mental upset? Such as shock, worry, dietary, overexertion, weather?
Does anything make it better? Worse?
Do you have any other health concerns? Please list in order of importance to you.

Please check if you have ever had any of these conditions:

	Yes
High Blood Pressure (Hypertension)
Arrhythmias or Irregular Heart Beats
Swelling (Edema)
Lung Disease (Pulmonary)
Congestive Heart Failure (CHF)
History of Heart Attack (MI)
Abnormal EKG
Kidney Disease
Anemia
Asthma
Bleeding/Clotting Disorder
Diabetes
History of Stroke
History of Anxiety
Night Sweats
Sudden Weight Loss
Skin Disorder
G6PD Deficiency (Retinal Disease)

If you said yes to any of the above, please describe:
Please check if you have ever had any of these conditions:

AbscessesAlcoholismAnemiaAppendicitisArthritisAshthmaCancerChicken PoxCold soresDepressionDiabetesEczemaEpilepsyEmphysemaGallstonesGoitreGonorrheaGoutHeadachesHeart troubleHypertensionHepatitisHerpesInfluenzaJaundiceKidney DiseaseLeukemiaLiver DiseaseMalariaMeaslesMental IllnessMononucleosisMumpsNosebleedsParasitesPelvic Inflammatory DiseasePneumoniaProstate DiseaseRheumatic FeverSexual AbuseSkin DiseaseStrep ThroatSinusitisStrokeSyphilisTonsilitisTuberculosisVenereal WartsWartsWhooping CoughWormsOther

How much of these substances do you use (per day/week/month)?

List any treatments, medicines, supplements and/or homeopathic remedies you are taking.

Any Major Surgeries?

Any Major Injuries?

	Injury	When?	Complications or long term effects
1
2
3
4
5

Family History
Please tell us what ailments affected your family. These can include:

AlzheimersAlcoholismAsthmaArthritisCancerDiabetesDepressionEpilepsyGonorrheaHypertensionHeart diseaseHepatitisMental IllnessPneumoniaSkin DiseasesSyphillisTuberculosisUlcersOther

Relationships

Patient Information