Patient:
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:
Current Physician and/or Healing Modalities: (Chiropractor, Acupuncturist, Physical Therapy)
Exercise, Type and Frequency:
Any specific medical diagnosis: (year and physician)
List any serious diseases in your FAMILY HISTORY, such as cancer, diabetes, hypertension, heart disease,
etc…
Mother: _______________________________
Father: _______________________________
Grandparents: ___________________________
Grandparents: _________________________
Are you Allergic to any substance or have seasonal allergies? Yes____ No____ If yes, please list:
1.
2.
3.
GASTROINTESTINAL - Please check all that currently apply to your health situation.
Belching
Mouth sores
Increased appetite
Bad breath
Excessive thirst
Decreased appetite
Hiccups
Problems swallowing
Nausea
Gas
Heartburn/Reflux/Indigestion
Vomiting
Abdominal pain
Parasites
Food sits in stomach
Constipation
Hemorrhoids
Peculiar tastes/smells
Diarrhea
Food allergies
Liver Problems
Loose stools
Desire for hot/cold foods
Hepatitis
Anal itching
Dark/Light/Bloody stools
Gallstones
Rectal pain
Colitis
Current weight _______ lbs
Headaches
Light sensitivity
Earaches
Migraines
Red/Itchy eyes
Ringing in ears
Concussions/ TBI
Failing vision
Dizziness
Pressure in eyes/ears
Poor night vision
Sores on lips/tongue
Eye pain
Spots in front of eyes
Grinding teeth
Chest pain
Yellow/Jaundice eyes
Poor hearing
Fainting
Motion sickness
Other:
HEAD, EYES, EARS & THROAT
GENERAL
Allergies
Sudden energy drop
Sleep too much
Fevers/Chills
Sleep too much
Insomnia
Hot or Cold intolerance
Nightmares
Nightmares
Spontaneous sweating
Swollen glands
Bleed or Bruise easily
Weakness
Cravings
Hair loss
Fatigue
Weight gain/loss
Other:
Auto-immune disease
Sudden energy drop, specify
time:
MUSCULOSKELETAL
Head pain
Hip pain
Leg cramps
Traumatic Brian Injury
Knee pain
Muscle atrophy
Neck pain
Foot/ankle pain
Muscle pain(s)
Back pain
Hernia pain
Hand/Wrist pain
Broken bones
Elbow pain
Brittle bones
Muscle spasms
Arm pain
Joint Swelling
Muscle weakness
Shoulder pain
Deformities of bones
Areas of numbness & Tingling
Rib pain
Joint swelling
Broken Ribs
Spinal Curvature
Mobility Limitations
NEUROPHYSIOLOGICAL/EMOTIONAL
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
Mood swings
Low Stress Tolerance
Paralysis
Confusion
Suicidal
Mental illness
FEMALES / TRANSGENDER/ GENDER NONCONFORMING INDIVIDUALS
Cycle length: ______ days
Vaginal dryness
Increased/Decreased libido
Days of bleeding: ______ days
Endometriosis
Hot flashes
Heavy/Light periods
Method of birth control:
Night sweats
Menstrual blood color: _____
Number of pregnancies: ____
Sexually transmitted illness
Menstrual pain
Number of children: _____
HPV positive:
Clots
Number of abortions: _____
Vaginal discharge/sores
PMS
Difficult birth/caesareans
Breast problems
Polycystic Ovarian Disease (PCOS)
Are you pregnant: Yes
Irregular/No Period
Date of last PAP: __________
Age at menopause: ______
Female Fertility Issues
Infertility
Number of miscarriages: ____
Use/d birth control pills
Tested for chlamydia: Yes No
Gender Transitioning
Sex affirmation surgery
No
Yes
No
Age menses began: _____
Combined Hormone Therapy
MALES / TRANSGENDER/ GENDER NONCONFORMING INDIVIDUALS
Prostrate problems
Painful/Swollen testicles
Discharge
Erectile dysfunction
Increased/Decreased libido
Sexually transmitted illness
Male Fertility Issues
Infertility
Undescended testicles
Sperm analysis normal Yes No
Immune issues like antisperm
antibodies
Gender Transitioning
Sex affirmation/realignment
Surgery
Anti-androgen drugs
Combined Hormone Therapy
Food Log
Date:
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Date:
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Date:
Breakfast
Snack
Lunch
Snack
Dinner
Disclaimer
 I, Keagha Kia Carscallen, am a Certified Core Synchronism Practitioner.
 Neither the State of North Carolina nor the federal government of the United
States licenses Core Synchronism Practitioners. Therefore, I am not a licensed
Health Professional.
 Is the right and responsibility of each competent adult to direct their own
health care.
 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
 I, __________________, hereby request and consent to treatment from
Source Medicine. 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 a fee of $65 will be charged.
 My signature confirms that I am aware of and agree to the above.
______________________________
________________________________
Signature
Print Name
______________________________
Date