Initial Patient Intake Forms
Full Name:____________________________ Age:____ Date of Birth:__________
Address: _____________________________________________________
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Today’s Date________________________ Evening Phone _______________________
Daytime Phone_______________________ E-mail______________________________
How did you hear about our clinic? Check all that apply: Friend___Dr. Referral___
Internet___ Other - please specify: _________________________________
Date of Birth_____________ Age____
Occupation________________________________ Married____ Single____
Divorced____ Co-habiting____ Widow(er)____
Primary Care
Physician_________________________________________________________
Other Health Care Providers_____________________________________________
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Do you take any:
Medication (prescription or over-the-counter). Please list.
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Vitamins, supplements?____________________________________________________
Caffeine?______ Alcohol?______ Tobacco?______ Recreational Drugs?______
Rate your energy level overall: Low 1 2 3 4 5 6 7 8 9 10 High
Rate your overall body temperature: Cold 1 2 3 4 5 6 7 8 9 10 Hot
Major complaint(s):
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Past medical history: (Please list any major illnesses, surgeries or hospitalizations and the
dates they occurred.)
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Any significant past or present emotional states? (i.e. depression, anxiety, grief, anger,
fear, etc.)
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How do your health issues affect your
Happiness?
Hobbies?
Work?
Other?
Have you been diagnosed with one of the following?
__Heart Disease __High Blood Pressure __Chronic Pain __Cancer
__Diabetes __Epilepsy __HIV/AIDS
__Arthritis __Stroke __Migraines
__Depression __Hepatitis __Anemia __Other __Asthma
Put a check mark by the symptoms that pertain to you
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___cold hands
__ cold feet
__ fatigue
__ feverish in the afternoon or flushes
__Heat sensation in hands, feet, chest __night sweats
__ catch colds easily __shortness of breath __sweat easily
__ general weakness
__ feel worse after exercise __dizziness
__ see floating black spots
__palpitations __restlessness __anxiety
__chest pain
__ insomnia __mental confusion
__cough
__nasal discharge
__nose bleeds
__sinus congestion
__dry mouth, throat, nose, or skin __allergies
__chills alternating with fever
__sneezing
__headache
__feel achy
__stiff neck/shoulders
__sore throat
__difficult breathing
__low appetite
__loose stools
__constipation
__abdominal bloating or gas after
eating
__fatigue after eating
__prolapsed organs (previously diagnosed) __bruise easily
__general feeling of heaviness in body __mental heaviness, sluggishness or fogginess
__swollen hands
__burning sensation after eating __large appetite
__bad breath
__mouth (canker)
sores
__bleeding, swollen or painful gums __heartburn
__belching __vomiting
__swollen feet __chest congestion __nausea __diarrhea
__diarrhea alternating with constipation __feel better after exercise
__pain in ribs or side
__ tight feeling in chest
__bitter taste in mouth __blood shot eyes __anger easily
__skin rashes
__headache at top of head __hot flashes
__dry eyes
__numbness of hands and feet __muscle spasms, twitching, cramping
__seizures
__sore, cold or weak knees
__low back pain
__frequent urination
__do you get up at night to urinate? __lack of bladder control __memory problems
__hair loss __ringing in ears
Urine is:
__clear __light yellow __dark yellow __reddish yellow __ cloudy __scanty _ has odor
__ burning __painful
__ difficult __urgent
Libido (sex drive) is: Low1 2 3 4 5 6 7 8 9 10 High
Please list 1-3 health goals that you have for the next 6 months:
For the next year?
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For those with the applicable anatomy
Please answer each question or check the appropriate response.
1. Are you currently pregnant? __yes __ no
2. The approximate date of your last menstrual period?
3. Number of children _____
4. Number of pregnancies______
5. Age of first period _______ 6. Age of Menopause
(if applicable)___________
7. Is your menstrual cycle regular?_________
a. Number of days from the start of one period to the start of the next________________
b. Average number of days of flow ________
c. the flow is: light1 2 3 4 5 6 7 8 9 10 heavy
d. The color is: __ red __dark red __ pale red __bright red __ brown
e. are there blood clots ? __ yes __ no
f. Do you have pain/cramps? __ yes __ no
__ before period __ during period __ after period
g. Do you have nausea or vomiting before or during period? __ yes __ no
__before __during
h. Do you experience any of the following before your period?
__ water retention __ breast tenderness or swelling
__ depression __ irritability __food cravings __ migraines
i. Do you have bleeding between periods?
j. Do you have any discharge between periods?
Please put a check mark by the symptoms that pertain to you.
__ coldness or numbness in the external genitalia
__pain or swelling of the testicles __ premature ejaculation __ erectile dysfunction
__prostate issues
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