Name:
Preferred Pronoun (he, she, they, them):
Phone:
Email:
Address:
Today’s Major Health Concern:
Date of Birth:
Height:
Weight:
Has this changed in the last 6-12 months? If so, please explain
Ethnic/Cultural Background:
Rx Medications Currently Taking:
Nutritional Supplements Currently Taking: (please attach an additional list if necessary)
Current Physician and/or Healing Modalities: (Chiropractor, Acupuncturist, Physical Therapy)
Exercise, Type and Frequency:
Any specific medical diagnosis/surgery: (year and physician)
List serious diseases in your FAMILY HISTORY (e.g. cancer, diabetes, hypertension, heart disease, etc.)
Mother/s
Father/s
Grandparent
Grandparent
List any substances to which you are allergic, including seasonal allergy substances.
1.
3.
2.
4.
All information provided is confidential and only will be used for your treatment plan, unless otherwise ordered by a duly authorized, legal
affidavit requiring disclosure and/or release of information.
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GASTROINTESTINAL (Place an ‘X’ in front of all that currently apply to your health situation.)
Abdominal pain
Anal itching
Bad breath
Belching
Colitis
Constipation
Dark/Light/Bloody stools
Decreased appetite
Desire for hot/cold foods
Diarrhea
Excessive thirst
Food allergies
Food sits in stomach
Gallstones
Gas
Heartburn/Reflux/Indigestion
Hemorrhoids
Hepatitis
Hiccups
Increased appetite
Liver Problems
Loose stools
Mouth sores
Nausea
Parasites
Peculiar tastes/smells
Problems swallowing
Rectal pain
Vomiting
Current weight:
Chest pain
Concussions/ TBI
Dizziness
Earaches
Eye pain
Failing vision
Fainting
Grinding teeth
Headaches
Light sensitivity
Migraines
Motion sickness
Poor hearing
Poor night vision
Pressure in eyes/ears
Red/Itchy eyes
Ringing in ears
Sores on lips/tongue
Spots in front of eyes
Yellow/Jaundice eyes
Lbs.
HEAD, EYES, EARS & THROAT
Other:
GENERAL (Place an ‘X’ in front of all that currently apply to your health situation.)
Allergies
Auto-immune disease
Bleed or Bruise easily
Cravings - sugar
Fatigue
Fevers/Chills
Hair loss
Hot or Cold intolerance
Insomnia
Nightmares
Nightmares
Sleep too much
Sleep too much
Spontaneous sweating
Sudden energy drop
Swollen glands
Weakness
Weight gain/loss
Lbs.
Sudden energy drop, specify time:
Other:
All information provided is confidential and only will be used for your treatment plan, unless otherwise ordered by a duly authorized, legal
affidavit requiring disclosure and/or release of information.
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MUSCULOSKELETAL (Place an ‘X’ in front of all that currently apply to your health situation.)
Arm pain
Areas of numbness & Tingling
Back pain
Brittle bones
Broken bones
Broken Ribs
Deformities of bones
Elbow pain
Foot/ankle pain
Hand/Wrist pain
Head pain
Hernia pain
Hip pain
Joint Swelling
Knee pain
Leg cramps
Mobility Limitations
Muscle atrophy
Muscle pain(s)
Muscle spasms
Muscle weakness
Neck pain
Rib pain
Shoulder pain
Spinal Curvature
Traumatic Brian Injury
Other ________________
Surgery:
NEUROPHYSIOLOGICAL/EMOTIONAL (Place an ‘X’ in front of all that apply to your health situation.)
Tremors/Seizures
Convulsions
Poor memory/Concentration
Regions of numbness
Fainting/Dizziness
Anxiety/nervousness
Head injury
Lack of coordination/Balance
Sadness
Bad temper
Tremors/Tics
Weepy
Worry/Over thinking
Fearful
Depression occasional
Mood swings
Low Stress Tolerance
Paralysis
Confusion
Suicidal
Mental illness
Other:
REPRODUCTIVE HEALTH
Prostrate problems
Increased/Decreased libido (I or D)
Discharge
Painful/Swollen testicles
Immune issues like anti-sperm antibodies
Infertility
Undescended testicles
Sperm analysis normal (Y or N)
Fertility Issues
Anti-androgen drugs
Sex affirmation/realignment surgery
Erectile dysfunction
Gender Transitioning
Combined Hormone Therapy
Endometriosis
Sexually transmitted illness (type & date):
All information provided is confidential and only will be used for your treatment plan, unless otherwise ordered by a duly authorized, legal
affidavit requiring disclosure and/or release of information.
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Vaginal discharge/sores
PMS
Breast problems
Hot flashes
Vaginal dryness
Night sweats
Heavy/Light periods (H or L)
Menstrual pain
Infertility
Use/d birth control pills
Clots
Increased/Decreased libido (I or D)
Irregular/No Period
Polycystic Ovarian Disease (PCOS)
Fertility Issues
Combined Hormone Therapy
Tested for chlamydia
HPV positive
I am pregnant
Sexually transmitted illness (type & date):
Other:
Date of last PAP
Number of pregnancies
Cycle length in Days
Number of miscarriages
Days of bleeding
Difficult birth/caesareans
Age menses began
Number of children
Age at menopause
Number of abortions
Menstrual Blood Color
Method of Birth Control
All information provided is confidential and only will be used for your treatment plan, unless otherwise ordered by a duly authorized, legal
affidavit requiring disclosure and/or release of information.
Copyright 2014
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Important note about Acutes:
From a Nature Cure and Natural Therapeutics perspective, “acutes” are the body’s natural
process to bring about a cleansing. It is a healing opportunity. For the practitioner, the goal of a
treatment is to create an internal environment in the body where everything (bones, muscle,
fascia, organs, nervous system, brain, energetics) are completely in synch with the cerebral
spinal fluid and the Core current (the life force intelligence). When a pattern of trauma or
mechanical misalignment (either from an injury, stress, accident, environmental factors,
emotional and/or physical abuse, etc) in the skeletal, nervous, brain, organ or energetic system
has been corrected, the body responds to those corrections through the acute process. This is
when the life force intelligence of the body increases to bring about a “cleansing” as the old or
dis-synchronistic movement pattern, is corrected and proper mechanics are re-established.
Acutes denote a certain intensity and of a short duration. They can present (to name a few) as a
fever, a skin rash/boil, headaches, increase of existing symptoms, irritability, and/or an
emotional release. Acutes can be uncomfortable, though often a necessary part of the human
body’s attempt and desire to establish a balanced and neutral state of health. Most acutes,
generally last 12-24 hours. Some acutes may last longer.
Support: While receiving treatments, having a good support system can be very helpful. Core
synchronism treatments are very deep acting and can bring up emotional, physical and/or
mental aspects of trauma. Identifying your support network: such as a therapist, faith-based
counselor or advisor, elders, friends, peers can be very helpful during this process.
All information provided is confidential and only will be used for your treatment plan, unless otherwise ordered by a duly authorized, legal
affidavit requiring disclosure and/or release of information.
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Food Log
Date:
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Date:
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Date:
Breakfast
Snack
Lunch
Snack
Dinner
All information provided is confidential and only will be used for your treatment plan, unless otherwise ordered by a duly authorized, legal
affidavit requiring disclosure and/or release of information.
Copyright 2014
Page 6 of 7
Disclaimer


It is the right and responsibility of each competent adult to direct their own
healthcare.
The information provided here is for educational purposes only and is not
intended to prevent, diagnose, nor prescribe remedies for the treatment of any
disease or medical condition. Nor is this information intended to displace the
care of a qualified health care provider.
Patient Consent to Treatment




Signature
I, (
), hereby request and consent to treatment from Source Medicine, LLC. I
realize that the particular therapeutic outcome of these treatments, individually
and jointly, cannot be predicted with certainty and no guarantee is made
regarding any particular result or outcome.
Payment is required at the time of service.
If you are unable to keep your appointment, please provide 24 hours notice of
the cancellation or the entire fee of the treatment will be charged (emergencies
are an exception).
My signature confirms that I am aware of and agree to the above.
Print Name
Date
Please check the box, if you do not wish to receive quarterly newsletters/emails.
All information provided is confidential and only will be used for your treatment plan, unless otherwise ordered by a duly authorized, legal
affidavit requiring disclosure and/or release of information.
Copyright 2014
Page 7 of 7