Intake Form

Intake Form
Please answer the following questions to the best of your knowledge. All of the information provided is

confidential. Please try to be as detailed as possible as it will help me complete a thorough evaluation of

your health. If you have any questions, please do not hesitate to ask. Thank you.
Today's Date:*
Name:*

First NameLast Name
Birth Date:

MonthDayYear
Gender:

FemaleMale
Height:
Weight:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Phone Number (Work)

Area CodePhone Number
E-mail:
EMERGENCY CONTACT:

First NameLast Name
Phone (Emergency Contact):

Area CodePhone Number
Are you:

SingleMarriedDivorcedWidowedLiving with partnerOther
Do you have children?

YesNo
If yes, how many?
Family Physician
Phone Number:

Area CodePhone Number
When was your last physical?
Are you under the care of any specialists?

YesNo
If yes, who?
Name, Specialty, and City
Are you receiving other health care?

YesNo
If yes, what kind?
Source of referral:
Does your extended health care plan cover EXTENDED HEALTH services?

YesNo
If yes, who?
Chief Complaints (in order of importance to you):
Who diagnosed the conditions above?
How, if at all, have these conditions been treated? Was it successful?
Medical History
Please describe your general state of health briefly:
Please check the following conditions which apply to you.

Alcoholism or substance abuseAnemia or sickle cellArthritis/joint diseaseBlood clots/phlebitisCancer (describe type in the field below)DiabetesDigestive (describe type in the field below)Bleeding easilyFrequent SinusitisGall Bladder TroubleHay Fever, Allergy, EczemaHearing LossHeart Attack, Heart Disease, Heart FailureHeart MurmurHeadachesHigh Blood PressureHigh CholesterolLung diseaseMental trouble/depression/anxietyPneumoniaRadiation or chemotherapyRheumatic FeverSeizures, EpilepsySerious Injury or Accident (describe type in the field below)Sexually Transmitted Disease (describe type in the field below)Skin Disease (describe type in the field below)StrokeThyroid DiseaseTuberculosisUrinary Difficulties (infection, etc.)History of InfertilityLiver Disease, Hepatitis, etc.Other
Describe any conditions:
Please indicate any serious conditions, illnesses or injuries, and any hospitalizations, along with approximate dates:
Do you frequently use any of the following?

AspirinLaxativesAntacidsDiet pillsBirth controlOther
Type of Birth Control

PillsImplantsInjectionsOther
Do you smoke?

YesNo
If yes, how long and how much ?
Do you consume alcohol?

YesNo
If yes, how much/many drinks per week?
Do you exercise?

YesNo
If yes, what do you typically do?
Do you use recreational drugs?

YesNo
If yes, indicate type, frequency, duration of use.
Do you have any allergies or sensitivities? (Please check all that apply):

Dairy productsWheatSoyEggsCitrusStrawberriesNutsPenicillinSulfa drugsAspirinTylenolDustPollenMoldBeesAnimalsOther
How would you rate your energy at this time (On a scale of 1 to 10)?
Please indicate what immunizations you have had:

DPT (diphtheria, pertussis, tetanus)Haemophilus influenza BHepatitis ATetanus boosterFluHepatitis BMMR (measles, mumps, rubella)Polio
When did you have your last tetanus booster?

MonthDayYear
Please indicate if any caused adverse reactions:
WOMEN ONLY
Reproductive History:
Age at 1 st menstrual period:
First day of most recent menstrual period:

MonthDayYear
Usual Flow (days):

HeavyModerateLight
Number of days between periods:
Clots in menstrual flow:

YesNo
Colour of flow:
Do you have:

Painful periodMissed periodsSpotting between periodsVaginal bleedingUnusual discharge/infectionRecurring vaginal infections
If you have gone through menopause, have you had any post menopausal bleeding?
Date of last Pap:

MonthDayYear
History of abnormal Pap?
Number of:
Pregnancies
Live Births
Abortions
Miscarriages
Have you experienced complications during pregnancy/delivery/other problems?
Contraceptive History:
What type of contraception do you use?
Any problems with the current method?
Men Only
Please indicate: 1 = mild/monthly; 2 = moderate/weekly; 3 = severe/daily
Prostate Problems
Difficulty with urination, dribbling
Interruption of stream during urination
Decreased sexual function
Waking to urinate at night
Difficult to start/stop urine
Pain/burning with urination
Feeling of incomplete bowel evacuation
Diet
Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)?
Describe a typical day’s diet
Breakfast:
Lunch:
Dinner:
Snacks:
Beverages (and total quantity):
Family History
Indicate if a close relative (parent, child, and sibling) has had any of the following:
Allergies

ParentChildSibling
Asthma

ParentChildSibling
Cardiovascular disease

ParentChildSibling
Cyst

ParentChildSibling
Cancer

ParentChildSibling
Diabetes

ParentChildSibling
Digestive

ParentChildSibling
Depression

ParentChildSibling
Drug abuse/alcoholism

ParentChildSibling
Easy Bleeding

ParentChildSibling
High Blood Pressure

ParentChildSibling
Headaches

ParentChildSibling
Kidney disease

ParentChildSibling
Liver Disease

ParentChildSibling
Lung Disease

ParentChildSibling
Other mental illness

ParentChildSibling
Seizures

ParentChildSibling
Thyroid disease

ParentChildSibling
Tuberculosise

ParentChildSibling
Any others:
Comments:
Environment
Occupation:
Hobbies:
Living Environment:
Are you exposed to significant tobacco smoke (work, home, etc.)?

YesNo
Are you frequently exposed to animals (work, pets, etc.)?

YesNo
How is your home heated?
Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe:
How would you describe the emotional climate of your home?
How stressful is your work, or other aspects of your life? How well do you handle these stresses?
Is there anything that you feel is important that has not been covered?
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Intake Form

Medical History

WOMEN ONLY

Men Only

Diet

Family History

Environment