Adult Intake Form
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully.
All of your answers will be held absolutely confidential, and will be released only to authorized medical personal
upon written consent.
DOB ___________________________ Age ___________
Telephone Numbers: Home # ________________Work # ________________ Cellular # ________________
Email address ____________________________________
Whom may we thank for your referral to this clinic?
Other Health Care Providers______________________________
Chief Health Concerns (in order of importance to you)
Supplements (attach separate sheet if necessary)
Complications, if any
How would you describe your present state of health? Excellent Good Fair Poor
How are your energy levels on average (please circle; 1 representing low and 10 representing high)
1 2 3 4 5 6 7 8 9 10
Was your mother in excellent health throughout her pregnancy while carrying you? Yes No
Were you breastfed within the first 10 hours after birth? Yes No Don’t know
How often do you have a bowel movement? once/day twice/day more than twice every few days longer
Is there anything unusual about your bowel movements? (colour, shape, amount, texture) ____________________
What do you feel your weakest organ system is and why? (ie: heart, kidney, lungs, etc..) ______________________
How many times each year do you have a cold, sinusitis, flu, sore throat or bronchitis?
How long do they usually last? _____________________ Where do they affect you most?
head/sinus throat/ears chest
Do you have any environmental or drug allergies/sensitivities?
(Please list) ________________________________________________________________________________________
Please list what vaccinations you have had and approximately when:
Haemophilus influenza B
Hepatitis A Hepatitis B
Tetanus; booster, when? ___________
MMR (Measles, Mumps, Rubella)
Any adverse reactions? _________________________
Circle any of the following that a close family member (parent, child, grandparent, sibling) has had and indicate who:
Cancer Diabetes Heart Disease High Blood Pressure Stroke Seizures Asthma
Hayfever Anemia Kidney Disease Tuberculosis Depression Schizophrenia Dementia
What is your primary source of water? ___________________________________________________
Are you exposed to significant environmental toxins or tobacco smoke in your home? _________________
How would you describe the emotional climate of your home? __________________________________
How stressful is your work, or other aspects of your life? _____________________________________
How do you handle these stresses? _____________________________________________________
What are your hobbies? ______________________________________________________________