PATIENT INTAKE

Name:

Birthdate:

Street:

City, State, Zip:

Phone Number:

Email Address:

Emergency Contact:

Please list your primary complaint, when you first noticed it, and how severe you consider it on a scale of 1-10, 10 being the most severe:

Please list any and all accompanying complaints or concerns:

Please list any medications, herbs, or supplements you currently take:

Do you have an infectious disease?

Do you have a pacemaker or a clotting disorder?

Do you experience headaches and if so, what is the frequency, nature, and location of your pain? Do you notice any triggers? What, if anything, brings you relief?

Do you experience dizziness, forgetfulness, or mental haziness? If so, please describe:

Do you experience poor vision, blurry vision, floaters, dry eyes, or red eyes, and if so, is it constant or intermittent? When did you first notice these symptoms?

Do you experience nasal congestion or have allergies (seasonal, environmental, pharmaceutical, food, etc.)?

Do you get cankersores, mouth ulcers, cold sores or notice any particular sensation in your mouth?

Do you experience tinnitus, chronic persistent ear wax, or hearing loss?

Do you notice a pit in your throat, especially when emotional or stressed?

Do you experience chest tightness or palpitations?

Do you experience any digestive disorders such as bloating, abdominal cramping, flatulence, discomfort after eating, etc?

Do you have any concerns with bowel movements such as constipation, diarrhea, loose stools, not fully evacuating, etc? What color are bowel movements? Do you ever notice undigested food? How many per day?

Any issues with urination? Is it clear or dark? Do you wake up at night to urinate and if so, how often?

Do you ever experience heaviness of the limbs?

Do you usually feel hot, cold or moderate? If temperature is not regulated, where do you notice it most?

Night sweating or spontaneous sweating?

What is your stress level like?

What is your energy level? Can you wake up in the morning and get going right away?

How is your appetite?

Please describe a typical day of eating, including beverages and cravings:

How is your emotional well-being?

For women:

Are you pre-menstrual, menstrual, menopausal, or post-menopausal?

Do you have children and if so, how many? Any complications with pregnancies or birth?

Are your periods regular? How long are your cycles?

Do you experience clotting?

History of candida, vaginal discharge, or UTIs?