Patient Intake Form

Patient Intake Form

Name:		Phone: Home			Work:
Street		Age:	Ht.		Wt.
City		Birthdate			Sex:
State	Zip	Occupation:
Email:
Physician:		Referred By:		Emerg. #:
Main Problem:				Onset:
Other Concurrent Therapies:

Past Medical History (include date):

Significant Illnesses: Cancer Diabetes High Blood Pressure Heart Disease Hepatitis
Rheumatic Fever Thyroid Disease Seizures Other:
Surgeries:
Significant Trauma (auto accidents, falls, etc.)
Birth History: (prolonged labor, forceps delivery, etc.)
Allergies: (drugs, chemicals, foods.)
Medicines taken within the last two months (include vitamins, over-the-counter drugs, herbs, etc.)
Occupational Stresses (Chemical, physical, psychological, etc.)
Exercise:
Comments:

Habits: Cigarettes Coffee Tea Cola Alcohol Dr.ugs Sugar Salt Other:

Family Medical History: Diabetes Cancer High Blood Pressure Heart Disease Stroke Seizures
Asthma Allergies Alcoholism Other:

GENERAL

SKIN AND HAIR

HEAD, EYES, EARS, NOSE, AND THROAT

CARDIOVASCULAR Copyright @ 1984 Redwing Book Company, Inc.

RESPIRATORY

Cough	Coughing blood	Asthma	Bronchitis
Pneumonia	Difficulty in breathing when lying down		Tight chest
Production of phlegm what color			Other lung problems

GASTROINTESTINAL

GENITO-URINARY

PREGNANCY AND GYNECOLOGY

MUSCULOSKELETAL

Neck pain	Muscle pains	Back pain(where)	Joint pains(where)
Other joint or bone problems?

NEUROPSYCHOLOGICAL

COMMENTS ON ANY OTHER PHYSICAL, EMOTIONAL, OR MENTAL SYMPTOMS

Poor appetite	Heavy appetite	Poor sleep	Heavy sleep
Insomnia	Fatigue	Tremors	Vertigo
Cold hands	Cold feet	Cold back	Cold abdomen
Fevers	Chills	Night sweats	Sweat easily
Cravings	Localized weakness	Poor coordination	Change in appetite
Sudden energy drop at (time)		Peculiar tastes/smells
Strong thirst (cold/hot drinks)		Bleed or bruise easily (where)

Rashes	Rashes	Rashes	Rashes
Eczema	Pimples	Dandruff	Loss of hair
Change in hair/skin texture	Purpura	Other hair or skin problem

Dizziness	Concussions	Migraines	Glasses
Eye strain	Eye pain	Poor vision	Night blindness
Color blindness	Cataracts	Blurry vision	Earaches
Ringing in ears	Poor hearing	Nose bleed	Sinus problems
Mucus	Dr.y throat	Dr.y mouth	Copius saliva
Teeth problems	Jaw clicks	Grinding teeth	Facial pain
Gum problems	Spots in eyes	Recurrent sore throats
Sores on lips or tongue	Headaches (where and when)
Other head or neck problems

High blood pressure	Low blood pressure	Chest Pain	Irregular heartbeat
Dizzines	Fainting	Cold hands/feet	Swelling in hands/feet
Blood clots	Phlebitis	Difficulty breathing	Other

Nausea	Vomiting	Diarrhea	Bowel Movement:
Gas	Belching	Black stools	Frequency
Bad Breath	Rectal pain	Hemorrhoids	Color
Constipation	Bloody stools	Sensitive abdomen	Odor
Pain or cramps	Laxative use:		Texture/form

Pain on urination	Frequent urination	Blood in urine	Urgency to urinate
Unable to hold urine	Kidney stones	Venereal disease	Impotency
Wake up to urinate How often/night;			Other G/U problems

Number pregnancies	Number births	Premature births	Miscarriages
Age at first menses	Period (days)	Duration	Irregular periods
Flow (describe)	Clots	Last PAP	Last menses
Vaginal discharge	Vaginal sores	Breast lumps	Menopause
Birth control type and duration		Changes in body/psyche prior to menstruation

Seizures	Areas of numbness	Poor memory	Concussion
Depression	Anxiety	Bad temper	Easily stressed
Treated for emotional problems			Considered/attempted suicide
Other neurological or psychological problems?