Elissa Gustafson DO(MP)
Absolute Health Science
202-21 Surrey St. W Guelph, ON N1H 3R3
Tel 519-827-9519 Fax 519-827-9520
egustafson@absolutehealthscience.com
PATIENT INTAKE FORM
Name:
Address:
City:
Occupation:
Province: ______ Postal Code:
_______ Phone (H): __________________ (Cell)
____
E-mail:
Male:  Female:  Date of Birth:
Emergency Contact:
Phone:
Relation:
Name of Medical Doctor: ________________________ Naturopath: ______________________
Chiropractor: _______________________ Massage Therapist (RMT): _____________________
Specialist: ___________________________ Other: ____________________________________
How did you hear about us?  Friend/Relative  Health Care Practioner  Website
Referred by: _______________________________________________
Health Concerns
What are your main health concerns, with approximate date of onset? Please list in order of
importance.
______
Medications & Habits
Allergies/Sensitives?
Medication/Supplements?
 Tobacco # of cigarettes/day__  Alcohol # of drinks/week___  Caffeine # cups/day____
Amount of water per day? ______________
# of pop/week: __________________
How many days a week do you exercise? __ Duration: _______ Type: ____________________
How many hours of sleep per night? _________ Quality of sleep: _______________
Current level of stress 1-10 (1 being no stress, 10 being highest) _________________
Medical History
Have you had any lab work or special studies (CT, MRI, X-Ray, etc)? ______________________
What treatments have you tried and what were the outcomes? ____________________________
Any hospitalizations, surgeries, implants, etc? _________________________________________
Elissa Gustafson DO(MP)
Absolute Health Science
202-21 Surrey St. W Guelph, ON N1H 3R3
Tel 519-827-9519 Fax 519-827-9520
egustafson@absolutehealthscience.com
Pain Rating Scale
On a scale of 1 – 10 (1 being no pain, 10 being worst pain ever) what would you rate your current
level of pain? _____
Pain Diagram
Please indicate areas of pain/discomfort:
Medical History
In the lists below, check all illnesses that you have experienced and mark an F for family history.
Measles
German Measles
Chicken Pox
Mononucleosis
Mumps
Whooping Cough
Scarlet Fever
Polio
Reye’s Syndrome
Worms/Parasites
Cholera
Malaria
Food Poisoning
Typhoid
Stomach/Duodenum Ulcers
Hiatal Hernia
Constipation
Crohn’s Disease
Appendicitis
Rheumatoid Arthritis
Osteoarthritis
Rheumatism
Back pain/Sciatica
Fibromylagia
Gout
Strep Throat
Sinusitis
Allergies (Environmental)
Genital Herpes
Genital Warts
Gonorrhea
Spleen Disease
Hypoglycemia
Jaundice
Hepatitis
Liver Disease
Pancreatic Disease
Bladder Problems
Prostate Problems
Diabetes
Gall Bladder Disease
Eye Problems
Diarrhea
Hay Fever
Kidney Problems
Acne, Boils, Impetigo
Shingles
Eczema
Keloids
Bronchitis
Pneumonia, Pleurisy
Asthma
Tuberculosis
Cushing’s Disease
Addison’s Disease
Hypothyroid
Hyperthyroid
Heart Problems
Heart attack, angina
Palpitation
Circulation Problems
Varicose Veins
Anemia
Raynaud’s Disease
Platelet Disorders
Miscarriage
Abortion
Gestational Diabetes
Uterine Prolapse
Pre-eclampsia
Other Pregnancy
Related Illness
Fibrocystic Breast
Disease
PMS
Uterine Fibroids
Endometriosis
Ovarian Cysts
Elissa Gustafson DO(MP)
Absolute Health Science
202-21 Surrey St. W Guelph, ON N1H 3R3
Tel 519-827-9519 Fax 519-827-9520
egustafson@absolutehealthscience.com
Psoriasis
Warts
Herpes (cold sores)
Urticara
Ulcers
Skin Cancer
Candida (yeast syndrome)
Irritable Bowel Syndrome
Colitis
Diverticulitis
Cancer, specify type:
Malnutrition
Rickets
Osteoporosis
Wilson’s Disease
Chronic Fatigue Syndrome
Environmental Illness
Human Papillovirus (HPV)
Chlamydia
Syphilis
HIV
Cancer, specify type:
Eating Disorder
Schizophrenia
Bipolar Disease
Clinical Depression
Suicidal Tendencies
Multiple Sclerosis
Lupus
Myasthenia Gravis
High Blood Pressure
Low Blood Pressure
Fainting
Vaginitis (recurrent)
Painful Periods
Infertility
Migraine Headaches
Dizziness
Numbness
Cramps
Epilepsy
Meningitis
Other:
Other:
Please check “√” if you are experiencing the following symptoms or write ‘P’ beside
the box if you have experienced these symptoms in the past.
General
Poor/Change in appetite
Nervousness
Weight gain
Weight loss
Cancer
Diabetes
Poor sleep
Fatigue
Allergies
Chills and fevers
Night sweats
Sweat easily
Cravings
Strong thirst
Skin and Hair
 Rash
 Itching
 Eczema
 Acne
 Loss of hair
 Thinning hair
 Dandruff
 Recent moles
 Dryness
 Hives or allergy reaction
 Boils
 Other skin problem(s)
Eyes Ears Nose Throat
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 Ear aches
 Ear infections
 Ringing in ears
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Sinus infections
Enlarged glands
Enlarged thyroid
Recurrent sore throat
Tonsillitis
Nasal obstruction
Post nasal drip
Nosebleeds
Headaches
Loss of taste/smell
Eye pain
Eye strain
Blurry vision
Vertigo
Impaired vision
Cataracts
Facial pain/tics
Jaw pain or clicks
Mercury fillings
Sores in mouth
Cardiovascular
 High blood pressure
 Low blood pressure
 Congestive heart failure
 Heart attack
 Phlebitis
 Stroke/cardiovascular
accident
 Pacemaker or similar
device
 Artificial valve
 Irregular heartbeat
 Dizziness
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Fainting
Chest pain
Varicose veins
Cold hands or feet
Swelling of limbs
Respiratory
 Difficulty breathing
 Chronic cough
 Bronchitis
 Asthma
 Emphysema
 Shortness of breath
 Coughing blood
 Throat phlegm
 Wheezing
Muscle, Bone & Joints
 Neck pain
 Back pain
 Muscle pain
 Muscle weakness
 Arthritis
 Bursitis
 Other pain
 Artificial joint
Gastrointestinal
 Indigestion
 Gas or burping
 Bad breath
 Constipation
 Diarrhea
 Incomplete bowel
movements
Elissa Gustafson DO(MP)
Absolute Health Science
202-21 Surrey St. W Guelph, ON N1H 3R3
Tel 519-827-9519 Fax 519-827-9520
egustafson@absolutehealthscience.com
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Abdominal pain or cramps
Nausea
Vomiting
Chronic laxative use
Rectal pain
Hemorrhoids
Blood in stool
Constant hunger
Colon trouble
Bloating
Gall bladder trouble
Intestinal worms
Jaundice
Neurological
 Loss of balance
 Irritable
 Poor memory
 Anxiety
 Depression
 Dizziness
 Lack of coordination
 Seizures/Epilepsy
 Concussion
 Loss of sensation
 Emotional problems
 Other psychological
 Hernia
Female
 Irregular periods
problem
Infections
 Hepatitis
 Tuberculosis
 HIV/AIDS
Genito-Urinary
 Frequent urination
 Urgency to urinate
 Pain on urination
 Wake up at night to
urinate
 Incontinence
 Kidney stones
 Kidney infection
 Blood in urine
Male
 Prostate problem
 Impotence
 Sores on genitals
 Pain
 Infertility/low sperm
count
 STD
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Heavy
Light
Clots
 Painful periods
 Vaginal discharge
 Pregnant
 Infertility
 Vaginal sores
 Sore breasts
 STD
Date of last Pap _____
Age of first menses __
Menopausal Y N
Age of last menses ___
Pregnant Y  N
Birth control? Y N
Type ____________
Number of:
 pregnancies
 abortions
 miscarriages
 births
SIGNATURE
I attest that the information provided is true and accurate to the best of my knowledge.
Signature:
Date: