Health History Intake FormPlease fill out the following intake form before your appointment. Name * First Name Last Name Address Email * Phone (###) ### #### Date of Birth * MM DD YYYY Marital Status Married Single Divorced Separated Primary Concerns * Personal History Do you have a history of: Allergies to food or drugs Anemia Arthritis Asthma, Pneumonia, TB Blood Pressure (High, Low) Cancer Chemotherapy / Radiation Treatment Chest Pain / Angina Contact Lenses Dental Treatment Complications Heart Surgery Hepatitis A or B or non A or B HIV Exposure Kidney or Bladder Disease Mononucleosis, Jaundice, Gallstones Pain in the ear, Ringing in the ear Popping, Clicking, Locking of jaw Diabetes Dizziness Fainting, Feet or Hand Swelling Glaucoma, Eye Surgery Heart Disease / Murmur Prolonged bleeding when cut Psychiatric Treatment Rheumatic Fever Shortness of Breath Stroke / Cerebrovascular Accident Thyroid Disease or Medication Ulcers, Intestinal Bleeding Venereal Disease History of any other diseases or problems Family history of any other diseases or problems: Please check and recent changed or concerns in the following areas: Dryness (skin, lips, hair, nails, colon, cough, etc) Insomnia Gas / Bloating Constipation Muscle twitching, cramping, numb, weak Joint pain, cracking Stiffness Shifting, tearing pain Cold extrememties Restlessness Worry, fear, anxiety Diarrhea, loose stool Nausea / Vomiting Migraines Rashes, acne, hives Bruise easily Excess Thirst Burning, sharp pain Bleeding Tenderness to touch Excess body heat Interrupted Sleep Anger, rage, envy, judgement, critical Congestion Food / Respitory allergies Edema Heaviness Dull, vague pain Cold clammy hands Frequent urination Excess oily skin Excess sleep Depression, greed, attachment, mental lethargy Coating on tongue Low fever, excess sleep Aches / Pains Malaise Lethargy Lack of energy Lack of taste, appetite Indigestion Sinking stool Energy Level Throat Eyes Ears Chest Lungs Heart Circulation Urine (cloudy, burning, odor, etc) For Female Clients Menopause Pregnant Birth control pills Regular menstrual cycles Heavy flow Moderate flow Light flow Menstrual pain Tender breast or PMS before period Dark menstrual blood Blood clots Medical & Practitioner History Are you currently under a physician or other health practitioners care for a specific medical problem or condition? If so, what for? What is the Dr's field of specialty? Prescription Drugs Non- Prescription Drugs Supplements, etc Surgeries Exercise and how often Diet Give an example of what you eat for breakfast, lunch, and dinner. Include beverages. Thank you!
