Confidential Patient Intake Form

Confidential Patient Intake Form
Please fill out the following form and submit
Patient Name
Date
D.O.B.
List your health concerns in order of importance:
Name and telephone number of primary care physician
Name of any other physicians you are currently under the care of
Family History
Age if Living
Age when Died
Reason for Death
Has anyone in your immediate family ever suffered from the following:
High Blood Pressure Heart Attack/Stroke Heart Disease Athsma/Allergies Mental Illness TB Auto Immune Diabetes Mellitus Osteoporosis Cancer
Cancer Type
Please list All Surgeries & Hospitalizations, including date occurred:
When was your Last (if applicable):
Blood Work Assessment:
Physical Exam
X-Ray
MRI/CAT Scan
Ultrasound
HIV Test
Last Dental Visit
Last Eye Exam
Did you receive a normal series of childhood vaccinations?
Yes No
Any vaccination reactions or other notes in vaccination history?
Do you currently used, or have you used the following in the past (Check or answer any that apply)
Antacids Steroids Analgesics Laxatives
Do you presently smoke or chew tobacco?
Yes No
Frequency
Age when Started
Date when Quit
Does anyone else smoke in your household?
Yes No
Coffee

Yes No
Cups per Day
Soda Pop

Yes No
Ounces per Day
Alcohol

Yes No
Drinks per Week
Do you presently or have you ever used recreational drugs?
Yes No
Type
Drug Addictions
Drug Treatment

Yes No
Do you currently take any prescription or over the counter medications?
Yes No
Medication and Dose
Reason Prescribed
Prescriber
Length of Time taking Medication
Any Side Effects Noted
Do you currently take and supplements?
Yes No
Medication and Dose
Reason Prescribed
Prescriber
Length of Time taking Medication
Any Side Effects Noted
Energy and Weight
Please indicate your energy on a scale of 1-10 (1=Poor, 10=Excellent)
If you are troubled by daytime fatigue, at what time do you experience this?
Present Weight
Weight one Year ago
Maximum Weight and When
Minimum Weight and When
Ideal Weight
Height
For the Next Section:

If applicable, please indicate if you currently, or have ever suffered from the following conditions in the past.
Skin and Head
Click to edit
Mouth/Throat
Rash Skin Cancer Hives Abnormal Perspiration Psoriasis/Eczema Itchy Dry Warts/Moles Headache Migraine Past Head Injury Oily/Dry Hair Hair Loss Nose Frequent Colds Nose Bleeds Chronic Congestion Post Nasal Drip Polyps Seasonal Allergies Eyes (Dry/Watery) Dark Under Eyes Double Vision Cataracts Glaucoma Styes
Canker Sores Cold Sores Persistent Sore Throat Gum Disease Dentures Cavities Odd Taste in Mouth Hoarseness Chronic Dry Mouth Swollen Glands
Respiratory
Cough TB Shortness of Breath w/ Exertion Bronchitis Shortness of Breath Sitting or Lying Down Pneumonia Wheezing Athsma
Cardiovascular
High Blood Pressure High Cholesterol Low Blood Pressure Murmurs Arrhythmias Palpitations Edema Chest Pain
Urinary Tract
Incontinence Discharge/Blood Urgency Kidney Stones Frequent Infections
Do you Get Up to Urinate at Night?
Yes No
How many Times?
Gastrointestinal
How often do you have a bowel movement?
Change in Appetite Indigestion Recent BM Change Bloating Diarrhea/Constipation Nausea Hemorrhoids Vomiting Gall Bladder Disease Heartburn Pancreaitis
Date of Last Colonoscopy
Male Genitalia
Testicular Pain/Swelling Sexually Active Hernia Prostate Disease/Symptoms Discharge Impotency
Do you perform a testicular self-exam?
Yes No
Female Genitalia
Age Periods Began
How Often Period Occurs
How Long Period Lasts
Are you sexually active?

Yes No
Do you have a healthy libido?

Yes No
Menstrual Cramping Heavy Menstrual Bleeding PMS Food Cravings Vaginal Dryness Pain with Intercourse STD Vaginitis Mammography
Times Pregnant
Number of Births
Miscarriages
Date of Last Pap Smear
Any abnormal paps? When?
Bone Density Test Date
Menopausal Since what Age?
Current Method of Birth Control
Please list any types of hormonal birth control used in the past and how old you were when you used this method:
Musculoskeletal
Weakness Arthritis Stiffness Leg Cramps Tremors Pain Nervous Paralysis Sciatica Tingling/Nimbness Carpal Tunnel Syndrome Seizuers Fainting
Emotional Health
Depression Anger/Irritability Suicidal High Strung/Tense Anxiety Fear/Panic Eating Disorder Psychiatric Hospitalization
Anything Else you Think We should Know about?
Should be Empty: