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Patient Intake Form

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Country
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Age
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Work Phone
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Height
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Weight
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Birthdate
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  • Sex
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Sex
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  • Marital Status
  • Marrie
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Marital Status
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Occupation
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Emergency Phone
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Physician
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Referred by:
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Main Problem
Main Problem
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Onset
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Other Concurrent Therapies
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Past Medical History
Past or Present
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Other Illness
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Surgeries
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Slgntjicant Trauma (auto accidents, falls,etc..)
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Birth History (prolonged labor, forceps delivery,etc..):
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Allergies (drugs,chemcals, foods):
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Medicines taken within the last two months: (include vitamins, over-the-counter drugs, herbs, etc.)
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Exercise:
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Lifestyle
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Morning
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Afternoon
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Evening
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Habits
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Other
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General
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Peculiar tastes/smells
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Bleed or bruise easily (where)
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Strong thirst (cold/hot drinks)
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Sudden energy drop at (time)
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Skin_Hair
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Other
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Head, Eyes, Ears, Nose, and Throat:
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Headaches (when and where)
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Recurrent sore throat
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Other
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Cardiovascular
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Other
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Respiratory
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Production of phlegm (what color)
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Respiratory
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Gastorintestinal
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What is the frequency, color, odor and texture/form of your bowels?
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If you use a laxative, how often per week?
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Genito-Urinary
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How often and what time do you wake up during the night to urinate
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Other Problems
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Pregnancy & Geneology
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How many Pregnancy's
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Any premature births?
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When was your last period?
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When was your last pap smear?
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How many live births?
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Age of 1st Menses
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Have you started menopause?
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When was your last Mammogram/breast exam?
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How many miscarriages?
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How many days does your period last?
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Birth Control type and duration
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Musculo-Skeletal
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Neuropsychological
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Relaxation Strategies
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Hobbies
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Comments
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