New Patient Intake Form | Dr. Barry Taylor

1) Do you consider yourself in good physical health?

Yes
No

2) Are you currently taking any medications?

Yes
No

If yes, what and for how long?

3) Do you take vitamin supplements?

Yes
No

If yes, what and for how long?

4) Do you have a history at any time in your life or do you currently have any of the following symptoms or body signs?

Headaches - How often?

Does not eating make them worse?

Yes
No

What makes them better?

Dizziness - How often?

Does it occur when you bend down to pick something up or get out of a bath quickly?

Yes
No

From missing a meal?

Yes
No

Heart palpitations - how often?

Check applicable symptoms

Kidney or bladder infections

Painful urination
Frequent urination
Burning urination
None of the above

Lung or respiratory conditions

Painful inhalation or exhalation
Frequent colds
Sinusitis
Wheezing
Shortness of breath
Allergies
Asthma
None of these

Skin

How often do you have a bowel movement?

Do you ever have blood with your stools?

Yes
No

Check applicable symptoms

Heartburn
Burping
Bloating
Nausea
Vomiting
Gas or flatulence
Diarrhea
Constipation
None of the above

5) Do you crave any specific foods?

Yes
No

If yes, which foods?

6) At any time in the past, or recently, have you consumed a lot of sugar, salt, meat, coffee, or any other food?

Yes
No

If yes, which foods?

Are you allergic to any foods? Are there any foods your body doesn't like, i.e. coffee -hyper, dairy -mucous, sugar -pre-menstrual symptoms or general fatigue, fatty, rich foods -indigestion, etc.?

7) Do you exercise regularly?

Yes
No

If yes, what do you do, for·how long, how many times per week and how long have you been doing this?

8) Have you ever or do you now drink alcohol more than 1 time per month?

Yes
No

If yes, how often and what?

9) Have you ever or do you now smoke tobacco or cigarettes?

Yes
No

If yes, what, how often, how long?

10) What other physical conditions or symptoms have you had recurring or do you have now? ie- headaches, nausea, low energy, etc.

11) What surgeries have you had?

12) What diet programs have you done in the past and when?

What were the results and did you have any symptoms?

13) Have you ever been hospitalized for psychiatric care?

Yes
No

14) Are you currently in therapy? If yes, please inform your therapist you are doing this program and your therapist must verbally O.K. your participation in this program?

Yes
No

15) Have you ever had an incomplete course in therapy?

Yes
No

Is there anything else we need to know about your physical or emotional health?

Please list at least 3 goals you are committed to accomplishing participating the the LOVE YOUR BODY workshop.

Name*

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Age*

Email*

Home Phone

Work Phone

Date*

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intake