Patient Health Intake Form
Note: This is a confidential record of your medical history and will be kept in this office. Information
herein will not be released to any person unless you have authorized us to do so in writing. Please
complete the questionnaire as thoroughly as possible. Thank you!
PERSONAL INFORMATION
(Name)Last, First, MI____________________________________________DOB_______ Age _____
Address: St.___________________________Apt#_____City _______________St. ____ Zip _______
Phone (day) _________________ (cell) _______________Occupation_________________________
Marital status _______________ SS#___________________________
Emergency Contact: _________________________________ Ph#_________________________
Primary Insurance Information (Please bring your ins. card with you)
Insurance Company:_____________________________ Ins Co. PH # _________________________
Insured Name:____________________________ DOB___________ SS#_______________________
Employer:____________________________ PH:#___________________
Relationship to patient: ______________________
What are your major health concerns that have brought you to seek medical attention?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
When did this begin? _______________________________________________________
________________________________________________________________________
Has anything recently changed or become worse? ________________________________
________________________________________________________________________
________________________________________________________________________
Have you had a diagnosis? If so, what was it, how was it arrived at, and by whom? _____
________________________________________________________________________
Are you currently receiving care from any other health professional?
Name: ___________________________________________________________________
What condition(s)? _________________________________________________________
Are you currently taking any medications, prescription or otherwise? YES ____ NO _____
Please list them: ___________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Do you have any infectious diseases that you know of? YES _____ NO _____
If yes, please list them:
__________________________________________________________________________________________
____________________________________________________________________________________
Are you pregnant? YES/NO If yes, how many months?____ What is your anticipated delivery date: ___________
1
Do you have any known allergies or sensitivities? If so, please list
them:____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Is there any reason why you could not take remedies made in alcohol?
________________________________________________________________________
Have you ever been hospitalized or had any surgeries? If so, please note date and reason:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
FAMILY MEDICAL HISTORY
Please complete this section only for family members with particular health issues.
AGE (If deceased, age at death and cause)
HEALTH PROBLEMS:
Father: ___________________________________________________________________
Mother:___________________________________________________________________
Brothers/__________________________________________________________________
Sisters:____________________________________________________________________
Children:___________________________________________________________________
Other close
blood relatives:_______________________________________________________________
PERSONAL HEALTH / HABITS
Height ________ Current weight ________ Weight 1 year ago __________
Do you smoke? ________ How many years? ________ Amount daily ________
Do you drink alcohol? ________ What? ________ Frequency ________
Do you use recreational drugs? ________ What? ________ Frequency ________
Do you drink coffee? ________ How many oz? ________ Tea? ________ How much? ________
Do you exercise regularly? Yes_____ No _____ Frequency? __________________________
Type of exercise? _____________________ Duration? _______________________________
Occupational Concerns
 Stress
 Hazardous Substances
 Heavy Lifting
Your Occupation _________________________________
 Other
HEALTH CONCERNS: Check off any experienced in the last year:
SKIN & HAIR:
 Change in skin texture
 Hives
 Rashes
 Eczema
 Pimples
 Itching
 Hair Loss
 Change in Moles
 Scars
 Bruises Easily
 Poor healing sores
2
EYES, EARS, NOSE & THROAT
 Poor vision
 Cataracts
 Glaucoma
 Earaches/Discharge
 Blurred vision
 Poor hearing or Loss
 Ringing in the ears
 Sore throat
 Canker sores
 Cold sores
 Grinding teeth
 Nose bleeds
 Facial pain
 Clicking jaw
 Eye pain
 Sinus congestion
 Mucous in throat
 Swollen glands
 Ear infections
 Dizziness
 Frequent colds
 Spots in front of eyes
 Bleeding gums
 Crossed eyes
 Difficulty swallowing
 Double vision
 Hay fever
 Hoarseness
 Persistent cough
 Vision – flashes/Halos
 High Blood Pressure
 Low Blood Pressure
 Chest pain
 Irregular heart beat
 Fainting
 Palpitations
 Cold hands or feet
 Poor circulation
 Rapid heart beat
 Swelling of feet/ankles
 Varicose veins
 Other:___________________________
 Cough
 Bronchitis
 Asthma
 Coughing blood
 Pneumonia
 Pain on breathing
CARDIOVASCULAR
RESPIRATORY
 Shortness of breathe without exertion
 Difficulty breathing when lying down
 Production of phlegm YES ____ NO ____ If yes, what color? _______________
 Other: _____________________________________________________________
GASTROINTESTINAL
 Nausea
 Hemorrhoids
 Black stools
 Constipation
 Excessive hunger
 Indigestion
 Abdominal pain
 Difficulty swallowing
 Mucous in stools
 Blood in stools
 Vomiting
 Gas
 Poor appetite
 Bad breathe
 Bloating
 Heartburn
 Food allergies
 Diarrhea
 Rectal pain/bleeding
 Bowel changes
 Excessive thirst
 Stomach pain
 Vomiting blood
 Other: _______________________________
# of bowel movements daily ______________ Loose Normal
Hard
3
URINARY
 Painful urination
 Frequent urination
 Blood in urine
 Urinary urgency
 Kidney stones
 Irregular flow
 Incontinence
 Inability to hold urine
 Decreased flow
 Frequent Infections
 Difficulty starting/stopping slow
 Other: _________________________________________________________
MUSCULOSKELETAL-Pain, Weakness or Numbness
 Neck
 Hand
 Shoulder/Arm
 Back
 Leg/Foot
 Reduced range of motion
 Other:_______________________________________________________
 Do you see a chiropractor or massage therapist? Yes / No (Name) ______________________
For how long? _________________
REPRODUCTIVE (Women Only)
Age at first menses: _______________
Date of Last Pap Smear__________________
Length of cycle: ___________________
Mammogram _________________
Duration of bleeding: _________________
 Heavy bleeding
 Cramps
 Breast lumps
 Pain with intercourse
 Vaginal Discharge
 Clots
 Unusual bleeding
 Irregular cycles
 Color: Brown / Black / Bright Red
 Abnormal Pap Smear
 Extreme Menstrual Pain
 Hot Flashes
 Nipple Discharge
 Migraines (Yes / No) Duration/frequency: _______________________________________________
PMS? If yes, what symptoms and how long before cycle do they start?___________________________
____________________________________________________________________________________
____________________________________________________________________________________
# of pregnancies _______
# of births ____ # of miscarriages _______ Premature births ________
Type of birth control used: ______________________________________________________________
Any other gynecological problems? ______________________________________________________
Reproductive (Men Only)
 Breast Lump
 Penis discharge
 Lump in Testicles
 Erection difficulties
 Sore on penis
 Other: ____________________________
4
NEUROPSYCHOLOGICAL
 Poor sleep
 Loss of balance
 Other: _________________________
 Depression
 Poor memory
 Numbness
 Seizures
 Irritability
 Anxiety
 Headaches
 High stress levels
 Migraine
 Lack of coordination
 Difficulty concentrating
 “Spacey” / foggy feeling
Hours of sleep per 24 hour day _____________________________ When?: AM PM Shift work
GENERAL
 Fatigue
 Depression
 Headaches
 Fevers
 Sweats/ Night sweats
 Dizziness
 Loss of Sleep
 Excessive thirst
 Slow metabolism
 Fainting
 Chills
 Weight loss
 Sudden energy drops
 Forgetfulness
 Nervousness
 Weight gain
 Intolerance to heat/cold
 Other:___________________________
CONDITIONS
 Aids
 Cancer
 Heart Disease
 Multiple Sclerosis
 Alcoholism
 Cataracts
 Hepatitis
 Pacemaker
 Anemia/Bulimia
 Chemical Dependency
 Herpes
 Pneumonia
 Anorexia
 Diabetes
 High Cholesterol
 Prostate Problem
 Appendicitis
 Emphysema
 HIV Positive
 Psychiatric Care
 Arthritis
 Epilepsy
 Kidney Disease
 Rheumatic Fever
 Asthma
 Glaucoma
 Liver Disease
 Scarlet Fever
 Bleeding Disorders
 Goiter
 Migraine Headaches  Stroke
 Breast Lump
 Gonorrhea
 Miscarriage
 Suicide Attempt
 Bronchitis
 Gout
 Mononucleosis
 Thyroid Problem
 Tonsillitis
 Chicken Pox
 Measles
 Mumps
 Tuberculosis
 Polio
 Typhoid Fever
 Ulcers
 Vaginal Infections
 Venereal Disease
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any
members of his/her staff responsible for any errors or omissions that I may have made in completion of this
form.
Signature _______________________________________________ Date __________________________
Reviewed _______________________________________________ Date __________________________
5
In addition to the above information, please include the following:
- 3-5 day diet diary, including snacks and water intake
- Supplements taken (both vitamins and herbal)
Include name of supplement
Manufacturer’s name
How many mg/mcg/iu in each tablet/capsule
Dosage: how many YOU take per day
- Copies of any recent lab work (within one year)
Notes:______________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Payment Policy
All copays are due and payable at each visit. There is an additional $5 charge if you forget your copay. There is a
$25 NSF charge for any returned check. There is a $25 No Show charge for any missed appointment that was not
cancelled prior to the appointment. There is also a $100 No Show charge for a missed appointment with a
LifeStyle Educator. Please be considerate and call at least 24 hours in advance if you cannot make your
appointment. If you are a private paying patient without insurance, all charges are due at the time of service. We
do not send statements to private paying patients.
Prescription Policy
Please do not wait until your last pill to call for a refill. There is a 24 HOUR turn around time for the nurses to call
the pharmacy. If you have not seen the Doctor in six months, the request for the prescription will be denied.
Assignment of benefits are payable to Dr. Kenneth C. Browning.
“I have read and understand the procedures and policies described above.”
Signature: ____________________________________
Date: ___________________________
6