Patient Intake Form

PATIENT DETAILS

Name:
Phone (Home):
Phone (Work):
Street:
City:
State/Province:
Postal/Zip Code:

Age:
Height:
Weight:
Birthdate:
Sex:
Occupation:

Physician:
Referred By:
Emergency Contact Phone Number:

Main Problem:
Onset:
Other Concurrent Therapies:

PAST MEDICAL HISTORY

Significant Illnesses:

CancerDiabetesHigh Blood PressureHeart DiseaseHepatitisRheumatic FeverThyroid DiseaseSeizuresOther

If Other, Please Note:

Surgeries (include date):

Significant Trauma (auto accidents, falls, etc.) (include date):

Birth History (prolonged labor, forceps delivery, etc.) (include date):

Allergies (drugs, chemicals, foods, etc.):

Medicines Taken Within Last Two Months (include vitamins, over-the-counter drugs, herbs, etc.):

Occupational Stresses (chemical, physical, psychological, etc.):

Exercise:

Comments:

Average Daily Diet

Morning:

Afternoon:

Evening:

Your Habits:

CigarettesCoffeeTeaColaAlcoholDrugsSugarSaltOtherNone of the Above

If other, please answer here:

Family Medical History:

DiabetesCancerHigh Blood PressureHeart DiseaseStressSeizuresAsthmaAllergiesAlcoholismOther

If other, please answer here:

Notes on Past Medical History:

GENERAL

(Select All That Apply)

Poor AppetiteHeavy AppetitePoor SleepHeavy SleepInsomniaFatigueTremorsVertigoCold HandsCold FeetCold BackCold AbdomenFeversChillsNight SweatsSweat EasilyCravingsLocalized WeaknessPoor CoordinationChange in AppetiteSudden Energy DropsPeculiar Tastes/SmellsStrong Thirst (Cold/Hot Drinks)Bleed or Bruise Easily

More Notes on General Health:

SKIN AND HAIR

(Select All That Apply)

RashesUlcerationsHivesItchingEczemaPimplesDandruffLoss of HairChange in Hair/Skin TexturePurpura

Other Notes on Skin and Hair:

HEAD, EYES, EARS, NOSE, and THROAT

(Select All That Apply)

DizzinessConcussionMigrainesGlassesEye StrainEye PainPoor VisionNight BlindnessColour BlindnessCataractsBlurry VisionsEarachesRinging In EarsPoor HearingNose BleedsSinus ProblemsMucusDry ThroatDry MouthCopious SalivaTeeth ProblemsJaw ClicksGrinding TeethFacial PainSpots in EyesRecurring Sore ThroatSores on Lips or GumsHeadaches

Other Head or Neck Problems:

CARDIOVASCULAR

(Select All That Apply)

High Blood PressureLow Blood PressureChest PainIrregular HeartbeatDizzinessFaintingCold Hands/FeetSwelling in Hands/FeetBlood ClotsPhlebitisDifficulty Breathing

Other Cardiovascular Problems:

RESPIRATORY

(Select All That Apply)

CoughCoughing BloodAsthmaBronchitisPneumoniaDifficulty in Breathing When Lying DownTight ChestProduction of Phlegm

Other Respiratory Problems:

GASTROINTESTINAL

(Select All That Apply)

NauseaVomitingDiarrheaGasBelchingBlack StoolsBad BreathRectal PainHemorrhoidsConstipationBloody StoolsSensitive AbdomenPain or CrampsLaxative Use

Bowel Movements (Frequency, Colour, Odor, Texture/Form:

Other Gastrointestinal Problems:

GENITO-URINARY

(Select All That Apply)

Pain on UrinationFrequent UrinationBlood in UrineUrgency to UrinateUnable to Hold UrineKidney StonesVenereal DiseaseImpotencyWake Up To Urinate

Other Genito-Urinary Problems:

PREGNANCY AND GYNECOLOGY

(Select All That Apply)

Number PregnanciesNumber BirthsPremature BirthsMiscarriagesAge at First MensesPeriod (days)DurationIrregular PeriodsFlow (describe)ClotsVaginal DischargeVaginal SoresBreast LumpsMenopauseBirth ControlChanges in Body/Psyche Prior to Menstruation

Last PAP:

Last Menses:

Other Pregnancy and Gynecology Problems:

MUSCULOSKELETAL

(Select All That Apply)

Neck PainMuscle PainBack PainJoint Pain

Other Musculoskeletal Problems:

NEUROPSYCHOLOGICAL

(Select All That Apply)

SeizuresAreas of NumbnessPoor MemoryConcussionDepressionAnxietyBad TemperEasily StressedTreated for Emotional ProblemsConsidered/Attempted Suicide

Other Neuropsychological Problems:

CLASSICAL

Your Preferences

Your Preferences - Season (Most Liked):

Your Preferences - Season (Least Liked):

Your Preferences - Taste (Most Liked):

Your Preferences - Taste (Least Liked):

Your Preferences - Climate (Most Liked):

Your Preferences - Climate (Least Liked):

Your Preferences - Time of Day (Most Liked):

Your Preferences - Time of Day (Least Liked):

Your Preferences - Temperature (Most Liked):

Your Preferences - Temperature (Least Liked):

Body Type:

Skin Colour:

Tone:

Odour:

Yin/Yang:

Firm/Weak:

Hot/Cold:

Surface/Interior:

General Comments

General Comments:

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