Patient Intake Form

Patient Intake Form

PLEASE ANSWER ALL QUESTIONS BELOW BEFORE SUBMITTING.
General Information
Name*

First nameLast name
Email*
example@example.com
Phone number*
Please enter a valid phone number.
Physical address*
City*
State*
Zip code*
Birthdate*

MonthDayYear
Date
Weight*
Height*
Dominant hand*
Blood type*
Emergency contact person*
What is your relation to this person?*
Emergency contact phone number*
Please enter a valid phone number.
Emergency contact email
example@example.com
What is your current profession*
What are your previous professions*
What is your country of origin (genetically)?*
Where were you born?*
Where were you raised?*

Stress & Relaxation
What do you do for fun?*
When & where was your last vacation?*
Do you relax daily?*

YesNo
What do you do to relax?*
What does your support system look like*
Have you ever smoked? (Y/N) If yes, then what and for how long?*
How well do you sleep?*
Do you take any kind of sleep aid, and if so, What and how often?*

PERSONAL AND FAMILY HEALTH HISTORY

Please fill out in detail - having your history greatly helps your practitioner serve you better!
Use this link to see an example of what types of information will be useful for the question below.

CLICK HERE
Provide a personal health history.
What time do you typically begin eating each day, and what time do you typically stop eating each day?*
What does your typical daily diet pattern look like? What do you typically eat for breakfast, lunch and dinner? Please include all beverages as well!*
Have you ever dealt with eating disorders? If yes, please describe.*
Have you ever been vaccinated? Which ones? And when?*
Do you have children?*

YesNo
If yes how many?*
Age of each child
Have any of your children been vaccinated? Which vaccines?
Do any of your children have any health symptoms or conditions? (e.g. ADHD or allergies or asthma)
Give a Health History for you & your Family Including; Name (First & Last), Date of Birth & Death if Applicable, Medication History, Health coonditions, Operations, & Hospitalizations. Please include; Mothers, & Fathers, Grandparents, siblings, Children, Aunts & Uncles, cousins.
Write out a family history.*
Any other relevant family history

STRESS/EMOTIONAL HEALTH
Have you had any emotional upsets or traumas in your life “recently”?*

YesNo
If Yes, can you please share what happened and the emotion it evokes?
Do you have regular practices for alleviating/managing your stress, and if so, what are they?*

Water
What kind of water do you currently drink? If filtered, what kind of filtration?
Do you drink tap water from restaurants?*

YesNo
If no, what do you drink at restaurants?
Do you drink tap water at work?*

YesNo
Do you shower in unpurified city water?*

YesNo

24 HOURS prior to your appointment, have you:*

Consumed Alcohol?Smoked or Taken Recreational Drugs?Had any you have any caffeine this morningHad a good night’s sleepNone Of The Above... I did all the preparatory things for todayI have read over the prep document
Please Read and by clicking submit you acknowledge, understand and agree with the information below.

I understand that Computerized Regulation Thermography (CRT) is not a primary diagnostic device as deemed by the U.S. Food and Drug Administration and is not to exclude other methodologies of cancer detection. Its purpose is to add information to the physician or practitioner to aid in the integration of other tests and results in order to achieve treatment outcomes, and not intended as diagnostic of any disease or dysfunction in itself. I agree to not hold the Thermography Report Writing Services responsible for any decision I or my doctor make based on the results obtained. I am ultimately responsible for payment to the Thermography Center and accept that the Center does not bill insurance companies. Payment is due at the time of service. You will be given a receipt for your visit, which you can submit to your insurance company for reimbursement. If the insurance company does not pay for the services, The Thermography Center assumes no responsibility for reimbursement.
Please Read and by clicking submit you acknowledge, understand and agree with the information below.

I have requested and do hereby authorize The Thermography Center (“The Center”) or any qualified and certified agents, independent contractors, or trainees of the Computerized Regulation Thermography (Alfa Sight 9000) System to perform adjunctive diagnostic screening test with the Alfa Sight 9000 for the sole purpose of information only. I understand that The Center is not a medical facility and will not be treating me or diagnosing any medical condition. I understand that the test data or readings from this procedure will be classified and categorized by an independent party familiar with the Alfa Sight 9000 and the data will be forwarded to my chosen medical professional for interpretation and medical care intervention. Regulation Thermography is an adjunctive NOT primary diagnostic tool. I am responsible for following up with my medical care with my physician and should not rely on this procedure for the diagnosis or treatment of any medical condition. I further understand all services of the Thermography Center of Dallas operates under the umbrella of a health ministry called Abundant Grace Ministry.

I certify that I have consulted with a representative of the Thermography Center of Dallas and have read all applicable literature given to me. I have read and fully understand all of the information presented in this Patient Consent and Release form for Diagnostic Screening. I certify that I am eighteen (18) years of age or older, of sound mind, and I am fully capable of executing this Patient Consent and Release form for Diagnostic Screening myself.
Confirm Today's Date and that you are Agreeing to ALL Terms Above*

MonthDayYear
Date
Do you agree to all Terms Above?*

Clear
Should be Empty:

	YES	NO
Hernias
Lumps, swelling, masses in testicles
Discharge or Sores
Painful Erections
Hormone Replacement Therapy
Testicular Pain
Prostate Disease
Difficult or Loss of Erection
Infertility
Vasectomy

	Yes	No
Do you have amalgam (silver) fillings in your teeth?
Have you ever had an amalgam removed?
If you had amalgams removed, was it done by a biological dentist using a safe protocol?
Did your mother have amalgam when pregnant with you?
Have you ever worked in a dental office?
Have you had any dental crowns?
Have you had any bridges?
Have you had any root canals?
Have you had any tooth extractions?
Do you have any dental implants, retainers or other metal in your mouth?
Did you wear contact lenses during the 1980’s or early 1990’s?
Did you take oral contraceptives during the 1980’s or early 1990’s?
Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?
Have you noticed any adverse reactions to these shots?
Do you have any tattoos with red ink?
Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

	Yes	No
Does your occupation involve soldering or metal salvage?
Have you done any old home repair or sandblasting?
Do you do a lot of painting?
Was your home built before 1978?
Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)
Are you around a lot of fake leather, or vinyl?
Do you get stomach aches in the morning?

	Yes	No
Have you ever lived near, on or by a golf course, freeway or tension wires?
Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)
Do you have your house sprayed with pesticides for pest control?
Do you spray herbicide (weed killers) in or around your home?
Do you use conventional insect repellants on your self or family?
Do you use conventional sunscreen?
Do you use conventional perfume or cologne every day?
Do you get your hair colored? If so, is it on the scalp?
Do you use aerosol hairspray?
Do you get your nails done?
Do you use air freshener in your house, work or car?
Do you drink filtered water?
Do you drink bottle water?
Do you have a water filtration system for your entire house or shower filtration?
Does your spouse or other family members work around chemicals?

	Yes	NO
Do you see mold growing at home, work or school?
Have you ever had water damage at home, work or school?
Does your home, workplace or school have a damp or mildew smell?
Does spending time in your basement cause or worsen your symptoms?
Does your basement ever get wet?
Do you have a crawl space?
Does your basement or crawl space have a sump pump?
Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?
Does your car have a mildew smell?
Does anyone in your home have asthma like symptoms?
Does anyone in your family have chronic sinus infections or irritations?

Patient Intake Form

Stress & Relaxation

PERSONAL AND FAMILY HEALTH HISTORY

Symptomology

STRESS/EMOTIONAL HEALTH

TOXIN EXPOSURE

DENTAL WORK

Water

FEMALE ONLY QUESTIONS!

MALE ONLY

Mercury

Lead

General Toxicity

MOLD

LYME DISEASE

Health History

MICROBIOME HEALTH

HEALTH PROFILE

	YES	NO
Have you ever been diagnosed with Lyme Disease?
Have you had dry sockets or infected tooth extractions?
Have you ever been bitten by a tick or recluse spider?
Have you ever seen a bulls-eye rash appear on any part of your body?
Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors?
Was your mother ever diagnosed with Lyme Disease?
Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), or an Autoimmune condition?
Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

	YES	NO
Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?
Does anyone in your family experience similar symptoms to yours?
Do you have any history of kidney dysfunction?
Do you or any immediate family member have a history with cancer?
Do you have any history of heart disease, myocardial infarction (heart attack), etc.?
Are you currently having any thoughts of suicide?
Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?
Do you have a history of strokes?
Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?
Have you ever been in an auto accident, fallen or received a major physical injury?
Are you in menopause?

	YES	NO
Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, Brussels sprouts or other vegetables?
Do you often have gas that has a sulfur or foul smell?
Are you sensitive to supplements?
Have you ever been vegan or vegetarian for any length of time?
Can you tolerate Meat?
Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?
Have you taken birth control or Hormone replacement therapy for any length of time?
If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?
Have been on antibiotics for any extended period of time or often as a child or adult?
Were you caesarian delivered?
Were you breast fed?
Does your gut temporarily feel better after a round of antibiotics?
Do you have 1 to 2 bowel movements a day?

	0	1	2	3	4
Anxiety
Mood swings
Enraged behavior or anger for no reason
Excessive shyness, timidity, social phobia (not typical to your personality)
Irritability (not typical to your personality)
Low body temperature (below 97.5℉)
Insomnia (can’t get to sleep or return to sleep)
Dizziness
Sound in ears (ringing or hearing your heart beat)
Psychological symptoms, even thoughts of suicide
Sensitivity to sound
Indecisiveness
Feeling of being overwhelmed or fearful
Metallic taste in your mouth
Bad breath
Bleeding gums
Sensitive teeth
Canker sores or other sores in the mouth
Floaters, shadows or swimmers when you read or look into the sky
Dyslexia or loss of place while reading, even as a child
Swelling eyelids
Peeling on top layer of skin (hands, feet)
Dry skin
Heart pain (angina) and you are under 45 years old
Depression
Gout (arthritic pain, especially in big toes)
Pain in shoulders or upper back
Twitching eyelids
Anemia (low iron/hemoglobin on blood test)
Wrist/ankle drop or weak extensor muscles
Hair falls out (not normal male pattern baldness)
Sensitivity to light
Fatigue after exercising (feeling worse)
Bad night vision or seeing halos around lights
Shortness of breath, with very little effort
Excessive thirst and/or frequent urination
Red eyes or tearing
Blurred vision at times
Morning stiffness
Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners
Chronic fatigue or weakness
Non-restful sleep
Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.)
Trouble processing new information
Word reversal or trouble finding words
Sensitivity to touch
Short-term memory loss
Chronic sinus congestion
Dry non-productive cough
Muscle twitching
Excessive sweating, especially at night
Joint pain-not necessarily true arthritis-can move from joint to joint
Difficulty losing weight regardless of diet or exercise
Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis
Frequent illness, prolonged illness or sick days
Numbness or weakness in arms and legs
Headaches
Trouble adding or dividing numbers in your head
Fluctuating constipation and diarrhea
Stomach pain for no apparent reason
Appetite swings
Frequent muscle aches, cramps, unusual sharp sudden pains
Rashes or rosacea
Cold extremities (hands and feet)