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.

Patient Name_______________________________________
DOB ___________________________ Age ___________

Address _________________________________________________________________

 Telephone Numbers: Home # ________________Work # ________________ Cellular # ________________

Email address ____________________________________

Whom may we thank for your referral to this clinic?

Emergency Contact

Occupation

Other Health Care Providers______________________________

Chief Health Concerns (in order of importance to you)

 1. ______________________________________________

2. ______________________________________________ 

3. ______________________________________________

4. ____________________________________________________



Supplements (attach separate sheet if necessary)

1.

2.

3.

4.

Medication
1.

2.

3.

Operations

1.

2.

 Complications, if any

1.

2.

3.

Major Illnesses/Injuries

1.______________________________________________________________________

2. ___________________________________________________________________________

_____________________________________________________________________________

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) ________________________________________________________________________________________ ________________________________________________________________________________


VACCINATION HISTORY

Please list what vaccinations you have had and approximately when:

 DPT

 Haemophilus influenza B

 Hepatitis A  Hepatitis B

 Influenza (flu)

 Tetanus; booster, when? ___________

 Polio

Small Pox

MMR (Measles, Mumps, Rubella)

 Chicken pox

 Other: ________________________

 Any adverse reactions? _________________________

FAMILY HISTORY

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

Arthritis           Other:

MISCELLANEOUS

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? ______________________________________________________________