Vreeland - Patient Intake Form rev. 8.15

Patient’s Personal Records

(Confidential)
Today's date

MonthDayYear
Full Name*

First NameLast Name
Nickname
Legal Guardian
(if under 18)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Preferred method of contact

EmailHome PhoneCell PhoneWork Phone
Age
Date of birth
Emergency contact
Emergency phone
Sex

MaleFemale
Marital status (optional)

SingleMarriedPartneredSeparatedDivorcedWidowed
Credit Card Policy – For your convenience the Vreeland Clinic keeps a copy of your credit card on file to expedite the processing of your requests. This allows us to send you test kits, order supplements, schedule paid phone consults, etc. without delay. We will never charge your card without your consent.
Credit Card #
Name on card
Exp. Date
Security Code
Occupation
Place of Employment
Job Description
Ex: heavy lifting, computer/sitting all day, stressful, etc.
Recreational Habits and Hobbies
How often do you work out and what you do for fun and relaxation
Referred by
Present Chief Complaint
Reason for your visit
When did your problem begin?
Explain how it began
Have you had this problem previously?
If so, when?
What concerns you most about your condition?
Does it bother your work, sleep, other?
Is it getting worse?

YesNo
Have you been given a diagnosis for your condition?
Have you had treatment for this condition?

YesNo
If treated, when?
Treated by
D.C., M.D., other
Treatment results?
Medications and Supplements
List all medications that you are presently taking, and how often
birth control, over-the-counter meds (Tums, aspirin…)
List all vitamins, herbs, etc. that you are taking on a regular basis
List any other doctors you are currently seeing and why
Related Health History

Some health conditions are a result of our environment in the way we live and work.
List any electrical items you may use at home or work.
Electric blankets, heating pads, computers, diagnostic machinery, etc.
List any chemicals you use around the home or at work.
Paint, varnish, photography chemicals, fertilizers, pesticides, asbestos, etc.
Do you have any mercury fillings? If so, how long have you had them?
Family Health History

Some health conditions are a result of hereditary weakness. Information about the immediate family members, brothers, sisters, parents, or grandparents will give us a better understanding of your total health picture.
Enter a relative (mother, father, grandmother, sister...) and their health problems. Click "save" to add another relative.
Past Medical History
List all surgeries, pregnancies, illnesses, childhood diseases, etc.
Social History
Tell us about any smoking, drinking, alcohol abuse, substance abuse, exercising… How much or how long?
Health Goal

In order to better serve your health goals please indicate the extent of the care you desire from the Vreeland Clinic.
Wellness care to optimize my health and reduce my probability of future illness including, but not limited to my present complaint.Relief of my present symptoms only. This may mean that the actual cause of the these symtoms may be left untreated.
Should be Empty:

Patient’s Personal Records

Present Chief Complaint

Medications and Supplements

Related Health History

Family Health History

Past Medical History

Social History

Health Goal