CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Thank you for taking the time to fill out the overview form. This information will greatly assist us in helping you achieve your health and wellness goals.
All information is strictly confidential as required by law and our center’s privacy policy.
INTAKE FORM
Name: __________________________________ Date: _______________ Date of Birth: _____________________
Address: _____________________________________________________________________________________
Email: ______________________________________ Occupation: _______________________ Age: ___________
Telephone
Mobile: ___________________________________ Home: ___________________________________
Emergency Contact Name: ______________________________________________________________________
Phone: __________________________ Relation: ________________________
Spouse/ Partner Name: __________________________________________________________________________
Children Names & Ages: _________________________________________________________________________
How did you hear about the Cameron Wellness Center? ________________________________________________
Health Information
Please list your health concerns in order of importance to you, and the date of onset:
1.
2.
3.
4.
5.
Please list your most stressful life experiences:
1.
Age: _______
2.
Age: _______
3.
Age: _______
4.
Age: _______
5.
Age: _______
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CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Supplements & Drug Medications
Please list all vitamins, minerals, herbs, and/or homeopathic remedies you are currently taking.
Supplement
Dose/day
How long
Reason
Please list all medications you are currently taking (prescription and over-the-counter).
Medication
Are the medications well tolerated?
medication:
Dose/day
Y
N
How long
If no, please list the adverse reactions or side effects and from which
In the last 10 years, approximately how many courses of antibiotics have you taken?
Medical History
Please indicate if you have had any of the following diagnostic tests performed:
Test
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Reason
Date
Notable finding
Thyroid Panel
Liver Panel
Complete blood count
Blood sugar test
Colonoscopy
Food Allergy
Heavy Metals
Digestive Stool Analysis
Cholesterol
Hormone level
EKG
Chest x-ray
Mammography
Thermography
Adrenal Function
Other
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CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Date of last physical exam: _____________ Findings: __________________________________________________
Please list any past surgeries or hospitalizations with approximate dates:
Please list all past injuries (i.e. broken bones, joint sprains, burns, falls, car accidents, etc.) with dates:
List all dental work and the approximate date of the procedure (root canal, mercury or ceramic filling, implants, caps,
dentures):
Indicate if you have had any of the following:
Childhood Illnesses
O Asthma
O Measles
O Rheumatic fever
O Chicken pox
O Mumps
O Scarlet fever
O Eczema
O Polio
O Whooping cough
O Frequent ear infections or colds
O Rubella
O Hepatitis A
O Diphtheria
O Pertussis
O Hepatitis B
O Mumps
O Rubella
O Tetanus
O Flu Shot
O Polio
Vaccination History
O
O
O
O
Measles
Small pox
Chicken pox
Shingles
Other Medical Procedures
O Joint replacement O Pacemaker
What is your blood type?
A+
O Pins or plates
B+
O+
AB+
A-
B-
Height: __________ Current Weight: __________ Weight 1 yr. ago: __________
Maximum weight: __________ When? __________ Desired weight: __________
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O-
AB-
CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Review of Systems
Circle if the symptom has occurred in the last year. Place a check mark if the symptom has occurred in the past.
General
weight gain
weight loss
significant wt. loss
significant wt. gain
history of dieting
chronic fatigue
afternoon fatigue
weakness
excessive thirst
anemia
night sweats
fever chills
sick more than 1 time/ yr
intolerance to heat
intolerance to cold
cold hands/ feet
other:
Skin
dry skin
itchy skin
rashes
hives
moist skin
bruising easily
acne
eczema
psoriasis
shingles
ringworm
athlete’s foot
moles
bumpy skin on back of arms
spider/ varicose veins
changes to nails
changes to skin
color
changes to moles
nail fungus
nail ridges
other:
Head
headaches
migraines
dizziness
vertigo
trauma
hair loss
other:
Eyes
dry eyes
watery eyes
itchy eyes
eye pain
red eyes
discharge from eyes
floaters
blurred vision
impaired vision
double vision
eyes sensitive to light
poor night vision
cataracts
vision loss
other:
vision correction:
vision: near/ far
contacts
glasses
laser
Ears
ear pain
itchy ears
waxy ears
discharge from ears
ringing in ears
hearing loss
ear infections
ear infections as a child
hearing aids
other:
Nose & Sinuses
itchy nose
discharge from nose
congested nose/sinuses
post nasal drip
nosebleeds
loss of smell
breathes through mouth
snores
other:
Mouth & Throat
dry mouth
itchy mouth/throat
sores on mouth/lips
hay fever/allergies
bad breath
root canals
implants
frequent sore throat
coughing up blood
persistent cough
difficulty swallowing
loss of taste
hoarseness
dentures
inflamed/bleeding gums
cavities
braces
teeth sensitivity
jaw clicks
TMJ
treatment for strep
as a child…
other:
Neck
neck pain or stiffness
swollen glands
trauma
other:
Respiratory
shortness of breath
wheezing
pain w/ breathing
chronic cough
coughing up blood
asthma
allergies
bronchitis/pneumonia
positive TB test
history of smoking
exposure to chemicals
exposure to solvents
exposure to particulates
history of 2nd hand
smoke
other:
Cardiovascular
high blood pressure
low blood pressure
high cholesterol
high glucose
chest pain
heaviness in legs
cold hands/feet
feel heart racing
chest tightness
difficulty breathing at
night
palpitations
swelling in ankles
heart fluttering
purple fingers/lips
irregular heartbeat
heart murmur
dizziness on standing
exhaustion with minor exertion
hemorrhoids
spider veins
calf pain at night
calf pain walking
other:
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CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Circle if the symptom has occurred in the last year. Place a check mark if the symptom has occurred in the past.
Gastrointestinal
poor appetite
excessive appetite
changes in appetite
excessive thirst
trouble swallowing
stomach pain
nausea/vomiting
burping/belching
abdominal pain
abdominal bloating
gas/flatulence
indigestion
heartburn/antacid use
constipation (<1 stool/day)
stool hard to pass
foul smelling stools
loose stools (break up
when in water)
diarrhea
blood in stools
black tar in stools
mucous in stools
undigested food in stools
stool shape:
-one piece
-hard little pellets
-breaks up in water
-other:
Endocrine
hypothyroid
hyperthyroid
hypoglycemia
excessive thirst
heat or cold intolerance
diabetes
fatigue
poor appetite
excessive hunger
seasonal depression
unexplained weight loss
easy weight gain
other:
Immune
slow wound healing
reactions to vaccinations
chronic fatigue syndrome
chronically swollen
glands
chronic infections
other:
Neurological
fainting
dizziness/vertigo
numbness or tingling
trembling hands
head trauma
poor concentration
memory loss
lack of alertness
loss of grip strength
loss of muscle tone
muscle weakness
head heavy
heavy extremities
other:
Urinary
frequent urination
urinate <3 times/day
can’t hold urine
urination with cough or
sneeze
light yellow urine
yellow urine
yellow dark urine
red urine
cloudy urine
strong smelling urine
Kidney infections
bladder infections
urination at night
pain/burning urination
dripping after urination
bed-wetting
other:
Musculoskeletal
pain in:
-arms
-shoulders
-upper back
-hips
-feet
-hands
-neck
-lower back
-legs
painful bones
tight shoulder muscles
swollen knees/elbows
numbness/tingling
burning
spasms/cramps
morning stiffness
chronic pain
loss of height
unable to sit straight
activities limited due to
pain
arthritis
herniated/slipped disk
tendonitis
osteoporosis
broken bones
other:
5
Color:
-yellow
-green
-light brown
-dark brown
-black
intolerance to specific foods
fatigue after eating
food sensitivity
anal itching
liver disease
gallbladder disease
treated for parasites
ulcers
hemorrhoids
other:
CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Women Only
Heaviest flow day:
Sexually active Y N
Age of first menses:
# of pads/tampons on heaviest day:
Which gender are you sexually
active with? -Men -Women –Both
Length of period:
# pregnancies:
Type of birth control:
Length of cycle:
# live births:
Type of STD control: condoms/
monogamy/ other:
Date of last menses:
Circle if the symptom has occurred in the last year. Place a check mark if the symptom has occurred in the past.
Women Only
Clots with period
Menstrual cramps
Wt. gain with period
Spotting between periods
PMS
Irritability
Moodiness
Tendency to cry
Bloating/swelling
Breast tenderness
Low back pain
Fatigue with period
Missed periods
Irregular periods
PMS
Lack of sexual desire
Vaginal itching
Vaginal discharge
Vaginal odor
Yeast infections
Vaginal mucosa dry
Painful intercourse
Painful masturbation
History of STDs Y N
Tested for STDs Y N
Uterine fibroids
Hysterectomy
Use of birth control pills for
greater than 10 yrs?
Monthly breast self-exam
Y N
Use of hormone
replacement:
Breast feed your child
Age of menopause: ____
# of mammograms
Hot flashes
Fibrous breast
Breast implants
Vaginal dryness
Abnormal mammogram
Difficulty conceiving
Changes in cycle
Moodiness
Menopause
Nipple discharge
Brain fog
Ovarian cysts
Other:
Men Only
Sexually active? Y N
Type of birth control:
History of STDs Y N
Sense of full bladder
Discharge from penis
Testicular lump
Difficult urinating
Sore on penis
Breast lump
Burning/pain w/ urination
Wake up to urinate
Infertile
Lack of sexual drive
Sexual difficulties
History of prostatitis
Enlarged prostate
Prostate exam? Y N
PSA test? Y N
Prostate cancer
Increased straining w/
urination
Hernias
Other:
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CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Please indicate whether any family members have had any of the following: (Include parents, siblings, maternal
grandparents (MGP), paternal grandparents (PGP), aunts, uncles. Include age and cause of death if applicable.)
Relation to you
Relation to you
O Alcoholism
O Diabetes
O Allergies
O Drug Abuse
O Alzheimer’s disease
O Heart disease
O Arthritis
O High blood pressure
O Asthma
O Kidney disease
O Cancer (indicate type)
O Osteoporosis
O Depression
O Stroke
O Epilepsy
O Anemia
O Autoimmune condition
O Glaucoma
O Skin condition
O Tuberculosis
O Thyroid condition
O Other medical illness
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CAMERON
Wellness Center
1945 S 1100 E Suite 100
801-486-4226
Salt Lake City, UT 84106 drtoddcameron.com
Please list all allergies (food, medication, environmental):
Rate your stress level (1=low, 10=high)
1 2 3 4 5 6 7 8 9 10
Which factors most contribute to your stress?
O health
O work
O money
O family
O marriage
Please describe:
What brings you joy?
Any additional information about your health that you would like to share:
Thank you for taking the time to fill out the overview form. This information will greatly assist us in helping
you achieve your health and wellness goals. All information is strictly confidential as required by law and our
center’s privacy policy.
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