Talus Wood Health Intake Form

Health Intake Form

Please fill in the form below. Thank you.
Full Name

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Date of Birth & Time

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDay-Month-YearHourMinutesAM/PM Option
Place of Birth
City, State, Country
Gender
Height & Weight
Feet & Inches? Pounds?
Martial Status
Are you sexually active? Do you have multiple partners?
Occupation(s)
What do you do with your time?
How did you hear about us? Where you referred by anyone?
Do you have any existing medical conditions?
Are you taking any medications, herbs or other remedies? If yes, which ones?
Do you have any previous injuries? Please give details
What would you like to get out of this treatment?

Should be Empty:

Rows	Often	Sometimes	Never	Don't Know
Joint pain or swelling
Stiffness of joints, back or neck
Movement of pain or swelling to different joints
Creaking, popping, cracking joints
Muscle pain or cramps
General Muscle Pain/Tenderness (fibromyalgia)
Hand stiffness
Foot pain (aches or burning)
Bone sensitivity, esp. the spine
Clumsiness
Backache
Rib soreness
Tendonitis
Gait disturbance

Rows	Often	Sometimes	Never	Don't Know
Headache (persistent / intermittent / severe / migraine-like)
Bell’s Palsy (facial paralysis)
Burning, stabbing or shooting pains
Tremors or unexplained shaking
Numbness in parts of body / extremities
Tingling sensations (crawling on skin)
Weakness or partial paralysis
Light-headedness, wooziness, fainting
Twitching of muscles
Poor balance, dizziness, difficulty walking
Increased motion sickness
Alternating warm / cool sensations
Constant low body temperature
Stroke symptoms, seizures
Taste / smell abnormalities
Abnormal blood flow in brain
Diminished reflexes
Hearing music or sounds others can’t hear
Visual, auditory or odor hallucinations
Restless legs or periodic limb movement disorder

Rows	Often	Sometimes	Never	Don't Know
Mood swings, irritability
Easily frustrated
Unusual depression
Crying impulses for no reason
Over-emotional reactions, crying easily
Panic or anxiety attacks
Rage, aggression
Insomnia (difficulty falling or staying asleep), sleep apnea, narcolepsy
Disturbed sleep: too much, too little, fractionated, early awakening
Nightmares
Paranoia
Suicidal thoughts
Obsessive-compulsive behaviors
Disorientation (getting or feeling lost)
Depersonalization (losing touch with reality, feeling “unreal”)
Low self-esteem
Bitterness, guilt, alienation
Bipolar, psychosis-like disorder

Rows	Often	Sometimes	Never	Don't Know
Memory loss (short or long term)
Distorted memory
Confusion, difficulty in thinking
Difficulty with focus, concentration, reading (“Brain fog”)
Inattention
Forgetting how to perform simple tasks
Speech difficulty (slurred, slow, hesitant)
Word finding trouble
Forgetfulness
Letter, number, word reversals
Stammering, stuttering speech
Going to wrong places
Getting lost in familiar places

Rows	Often	Sometimes	Never	Don't Know
Floaters
Double or blurry vision
Eye pain, pressure in eyes
Light sensitivity
Tearing eyes, dry eyes
Vision loss, Blindness
Swelling around eyes
Flashing lights

Health Intake Form

Lyme Disease Evaluation

Three Doshas Questionnaire

Five Element Questionnaire

Rows	Often	Sometimes	Never	Don't Know
Decreased hearing in one or both ears
Buzzing, clicking or ringing
Sound sensitivity
Pain in ears

Rows	Often	Sometimes	Never	Don't Know
Diarrhea / Constipation
Abdominal pain / Bloating
Irritable bladder (trouble starting, stopping)
Frequent need to urinate
Upset stomach, vomiting
Gastroesophageal reflux (acid reflux or GERD)
Anorexia

Rows	Often	Sometimes	Never	Don't Know
Shortness of breath
Chest pain
Night sweats / Unexplained chills
Heart palpitations, extra beats, pulse skips
Heart block / Heart attack
Heart murmurs / Valve prolapse
Elevated or low blood pressure
Frequent and easy bruising of skin
Cough (odd, unexplained)

Rows	Often	Sometimes	Never	Don't Know
Loss of sex drive
Sexual dysfunction
Unexplained menstrual pain, irregularity
Unexplained breast/nipple pain, discharge
Testicular or pelvic pain

Rows	Often	Sometimes	Never	Don't Know
Neck stiffness, pain, creaks, cracks
Twitching of facial or other muscles
Painful teeth or gums
Difficulty swallowing
Sore throat
Unexplained hair loss
Scalp rash
Hoarseness, drippy nose (unexplained)

Rows	Often	Sometimes	Never	Don't Know
Extreme, persistent fatigue, poor stamina
Symptoms change, come and go
Pain moves to different body parts
Unexplained weight gain or loss
Malaise
Any type of rash / Itching
Night sweats (drenching)
Unexplained sweating
Swollen glands
Unexplained fevers (high or low)
Continual infections (sinus, kidney, yeast, bladder)
Increased sensitivity to allergens
Exaggerated response to alcohol or sugar
Sugar craving
Nodules under the skin
Experience of flu-like symptoms, and have not felt well since

Rows	Positive diagnosis	Negative diagnosis	Don't Know
Multiple Sclerosis
Parkinson’s Disease
Lupus, Gout, Hepatitis
Carpal Tunnel Syndrome
Meniere’s disease / TMJ (jaw pain)
Fibromyalgia
Rheumatoid Arthritis
Chronic Fatigue Syndrome
ALS (Lou Gehrig’s Disease)
Crohn’s Disease
Psychological/psychiatric symptoms
ADHD (Attention Deficit Hyperactivity Disorder)
Epstein-Barr virus infection

Rows	Often	Sometimes	Never	Don't Know
Fever
Fatigue
Headache
Poor appetite; stomach pain, vomiting
Burning pain on skin or in joints/ soles of feet
An unusual looking streaked rash;
Other skin symptoms such as purple blotches, dimples, sags and pustules
Swollen glands (especially around the head, neck and arms)
Lower abdominal pain
Enlarged lymph nodes
Sore throat - the bartonella bacteria invades the salivary glands of every organism it infects. Pain
Bone pain- shin bone
Anemia- Bartonella can scavenge nutrients from red blood cells
Depression
Anger/ rage
Little crazy
Suicidal
Poor balance
Brain fog
Decreased cognition
Memory impairment
Insomnia
Restlessness

Rows	a lot like you	somewhat like you	neutral	not much like you	nothing like you
1. I have been feeling worried or anxious.
2. I've been having difficulty falling asleep or have been awakening easily.
3. I feel restless if I'm not constantly on the move.
4. My digestion is irregular with frequent gas or bloating.
5. My bowel movements are hard, dry or occur less than once per day.
6. My daily schedule of eating meals, going to sleep or awakening often varies from day to day.
7. I tend to be impulsive.
8. I often forget things after a short period of time.
9. I have a lot of initiative but have trouble following through.
10. I generally have a number of physical concerns.

Rows	a lot like you	somewhat like you	neutral	not much like you	nothing like you
1. I have been feeling irritable or impatient.
2. I tend to be critical and am intolerant of errors.
3. My skin feels hot and irritated, or breaks out easily.
4. I have been having acid indigestion or heartburn.
5. I tend to be compulsive and have difficulty stopping once I've started a project.
6. I am easily frustrated by other people's incompetence.
7. Spicy foods, while I might enjoy them, usually do not agree with me.
8. I am strongly opinionated and tend to share my point of view without being asked.
9. I often feel as if I am overheated or have a low grade fever.
10. When provoked I can be sarcastic or biting.

Rows	a lot like you	somewhat like you	neutral	not much like you	nothing like you
1. I am currently overweight and have difficulty losing extra pounds.
2. I have a slow digestion and feel heavy after eating.
3. I commonly experience sinus congestion or excessive phlegm in my respiratory tract.
4. I have difficulty leaving a relationship, even after it is no longer nourishing.
5. I often deal with conflict by withdrawing.
6. I easily accumulate clutter in my life.
7. I have difficulty getting going in the morning.
8. I like to maintain a routine and resist changing my pace.
9. Given a choice, I prefer to watch rather than participate in an athletic activity.
10. I regularly feel drowsy or sluggish after a meal.

Rows	a lot like you	somewhat like you	neutral	not much like you	nothing like you
Are you a natural born initiator?
Do you have problems with authority figures?
Do you suffer from pains that migrate?
Do you act assertively and confidently?
Does other people's slowness and clumsiness irritate you?
Do you like struggling against great odds to prove to others you can do it?
Are you frequently doing something or going somewhere?
Do you have high blood pressure?
Have you often been told you don't compromise much?
Are you driven to be the first and best?
Does confinement and sitting quietly drive you crazy?
Do you get frequent muscle cramps?
Do you like to make the rules and then break them?
Are you passionate about everything you do?
Do you like pioneering new trails?
Do your nails alternate between hard and thick and dry and brittle?
Are you impatient with uncommitted people?
Are you afraid to show vulnerability?
Have you ever had tendonitis?
Do you love speed and adventure?
Do you tend to manipulate people and situations to get what you want?
Is controlling your anger one of your biggest problems?
Do you find any kind of restraint insufferable?
Do you do your best work under pressure?
Are you characterized as a type "A" personality?
Your favorite color is green.