"Patient Intake Form"

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Symptoms
Major Complaint:___________________________________________________________________________________
Start of symptoms?_______________________________________ Are symptoms/condition getting worse? Yes
No
What aggravates it?___________________________________What relieves it?_________________________________
Rate the severity of pain (0-none to 10-severe) : AREA 1:___________ 0 1 2 3 4 5
6 7 8
9
10
AREA 2:___________ 0 1 2 3 4 5
6 7 8
9
10
OTHER:___________ 0 1 2 3 4 5
6 7 8
9
10
Is the pain constant or does come and go?________________________________________________________________
What activities are difficult? Sitting
Standing
Lying Down Bending Walking
Other____________________
Description of the pain: Sharp
Dull
Aching
Burning
Shooting
Throbbing
Numbness
Tingling
Stiffness
Cramping
Swelling
Other____________________________________________________________
Have you ever had the same or similar condition/symptoms before? Yes
No
If yes, when?_____________________
Have you already received other treatment for your current condition?__________________________________________
Please list any other healthcare providers that you are currently under their care:
Provider Name_________________________________________________Date of last visit_____/_____/_______
Provider Name_________________________________________________Date of last visit_____/_____/_______
Provider Name_________________________________________________Date of last visit_____/_____/_______
Body Chart
What desired activities are you unable to do
Shade your symptom area. Place an “S” for sharp pain, a “T”
because of your condition or pain?
for tingling, a “N” for numbness and a “D” for dull pain:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Daily Habits
Do you exercise regularly? Yes No
Describe?_________________________________________________________
Do you smoke or use tobacco products? Yes No How much per day?_________________________
How much alcohol do you consume on a weekly basis?______________________________________
How much coffee, tea, or other caffeinated beverages do you consume per day?___________________
Patient Name:_____________________________________Date:_____/_____/_______Patient I.D.______________
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Symptoms
Major Complaint:___________________________________________________________________________________
Start of symptoms?_______________________________________ Are symptoms/condition getting worse? Yes
No
What aggravates it?___________________________________What relieves it?_________________________________
Rate the severity of pain (0-none to 10-severe) : AREA 1:___________ 0 1 2 3 4 5
6 7 8
9
10
AREA 2:___________ 0 1 2 3 4 5
6 7 8
9
10
OTHER:___________ 0 1 2 3 4 5
6 7 8
9
10
Is the pain constant or does come and go?________________________________________________________________
What activities are difficult? Sitting
Standing
Lying Down Bending Walking
Other____________________
Description of the pain: Sharp
Dull
Aching
Burning
Shooting
Throbbing
Numbness
Tingling
Stiffness
Cramping
Swelling
Other____________________________________________________________
Have you ever had the same or similar condition/symptoms before? Yes
No
If yes, when?_____________________
Have you already received other treatment for your current condition?__________________________________________
Please list any other healthcare providers that you are currently under their care:
Provider Name_________________________________________________Date of last visit_____/_____/_______
Provider Name_________________________________________________Date of last visit_____/_____/_______
Provider Name_________________________________________________Date of last visit_____/_____/_______
Body Chart
What desired activities are you unable to do
Shade your symptom area. Place an “S” for sharp pain, a “T”
because of your condition or pain?
for tingling, a “N” for numbness and a “D” for dull pain:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Daily Habits
Do you exercise regularly? Yes No
Describe?_________________________________________________________
Do you smoke or use tobacco products? Yes No How much per day?_________________________
How much alcohol do you consume on a weekly basis?______________________________________
How much coffee, tea, or other caffeinated beverages do you consume per day?___________________
Patient Name:_____________________________________Date:_____/_____/_______Patient I.D.______________
Page 3 of 4
Health and Medical History
-Circle all the present conditions, and underline the past conditions. List
approximate date condition began.
Acid Reflux
Constipation
Headache
Migraines
Low Blood Pressure
AIDS/HIV
Depression
Heart Disease
Memory Loss
High Cholesterol
Allergies
Diabetes
Hepatitis
Miscarriage
Psychiatric care
Anemia
Diarrhea
Herniated Disc
Mononucleosis
Rheumatoid Arthritis
Anorexia
Difficulty Sleeping
Herpes
Multiple Sclerosis
Stroke
Appendicitis
Dizziness
High Blood Pressure
Muscle Weakness
Seizures
Asthma
Emphysema
Insomnia
Mumps
Shortness of Breath
Bloating
Epilepsy
Irritability
Osteoporosis
Nausea
Bronchitis
Fainting
Kidney Disease
Osteopenia
Vertigo
Bulimia
Fatigue
Liver Disease
Pacemaker
Nervousness/Anxiety
Cancer
Fever
Light Sensitivity
Indigestion
Suicide Attempt
Cataracts
Fractures
Loss of Smell
Pneumonia
Scoliosis
Parkinson’s
Chicken Pox
Glaucoma
Loss of Libido
Thyroid Disorder
Cold Sweats
Goiter
Low Energy
Polio
Tonsillitis
Cold Feet or Hands
Gonorrhea
Measles
Prostate Disorder
Tuberculosis
TMJ Problems
Ulcers
Whooping Cough
Vaginal Infection
Prosthesis
Other_____________________________________________
Women only: Are you pregnant? No
Yes
If Pregnant: Date of Last Menstrual Period: _______________
Number of weeks? ___________________
Nursing?
No
Yes
Are you taking birth control pills? No
Yes
List Family history of illnesses known:
Mother:
Father:
Grandparents:
Siblings:
Aunties/Uncles:
List any surgeries or procedures which you have had:
________________________________________________Date_____/_____/______
________________________________________________Date_____/_____/______
________________________________________________Date_____/_____/______
List any allergies you have:____________________________________________________________________________
List any medications or nutritional supplements you are currently taking:_______________________________________
__________________________________________________________________________________________________
Patient Name:_____________________________________Date:_____/_____/_______Patient I.D.______________
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