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 PressureHeart Attack/StrokeHeart DiseaseAthsma/AllergiesMental IllnessTBAuto ImmuneDiabetesMellitusOsteoporosisCancer
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?
YesNo
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)
AntacidsSteroidsAnalgesicsLaxatives
Do you presently smoke or chew tobacco?
YesNo
Frequency
Age when Started
Date when Quit
Does anyone else smoke in your household?
YesNo
Coffee

YesNo
Cups per Day
Soda Pop

YesNo
Ounces per Day
Alcohol

YesNo
Drinks per Week
Do you presently or have you ever used recreational drugs?
YesNo
Type
Drug Addictions
Drug Treatment

YesNo
Do you currently take any prescription or over the counter medications?
YesNo
Medication and Dose
Reason Prescribed
Prescriber
Length of Time taking Medication
Any Side Effects Noted
Do you currently take and supplements?
YesNo
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
RashSkin CancerHivesAbnormal PerspirationPsoriasis/EczemaItchyDryWarts/MolesHeadacheMigrainePast Head InjuryOily/Dry HairHair LossNoseFrequent ColdsNose BleedsChronic CongestionPost Nasal DripPolypsSeasonal AllergiesEyes (Dry/Watery)Dark Under EyesDouble VisionCataractsGlaucomaStyes
Canker SoresCold SoresPersistent Sore ThroatGum DiseaseDenturesCavitiesOdd Taste in MouthHoarsenessChronic Dry MouthSwollen Glands
Respiratory
CoughTBShortness of Breath w/ ExertionBronchitisShortness of Breath Sitting or Lying DownPneumoniaWheezingAthsma
Cardiovascular
High Blood PressureHigh CholesterolLow Blood PressureMurmursArrhythmiasPalpitationsEdemaChest Pain
Urinary Tract
IncontinenceDischarge/BloodUrgencyKidney StonesFrequent Infections
Do you Get Up to Urinate at Night?
YesNo
How many Times?
Gastrointestinal
How often do you have a bowel movement?
Change in AppetiteIndigestionRecent BM ChangeBloatingDiarrhea/ConstipationNauseaHemorrhoidsVomitingGall Bladder DiseaseHeartburnPancreaitis
Date of Last Colonoscopy
Male Genitalia
Testicular Pain/SwellingSexually ActiveHerniaProstate Disease/SymptomsDischargeImpotency
Do you perform a testicular self-exam?
YesNo
Female Genitalia
Age Periods Began
How Often Period Occurs
How Long Period Lasts
Are you sexually active?

YesNo
Do you have a healthy libido?

YesNo
Menstrual CrampingHeavy Menstrual BleedingPMSFood CravingsVaginal DrynessPain with IntercourseSTDVaginitisMammography
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
WeaknessArthritisStiffnessLeg CrampsTremorsPainNervousParalysisSciaticaTingling/NimbnessCarpal Tunnel SyndromeSeizuersFainting
Emotional Health
DepressionAnger/IrritabilitySuicidalHigh Strung/TenseAnxietyFear/PanicEating DisorderPsychiatric Hospitalization
Anything Else you Think We should Know about?
Should be Empty: