Comprehensive Adult Intake Form
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Dr. Laura Hanson 1532 Dunwoody Village Pkwy Suite 150 Dunwoody, GA 30338 (770) 853-0945 www.connectmybrain.com Name: (First) _______________________ (Last) _____________________________ Age: ______________ Birth Date: ________________ Gender: □M □F Address: _____________________________________________________________________ City: _________________________________ State: ____________ Zip Code: _____________ Cell Phone Number: (_______) ____________________________ Work Phone Number (_______) ____________________________ Home Phone Number (_______) ____________________________ E-mail Address: _________________________________________@_____________________ How did you hear about our office? ________________________________________________ _____________________________________________________________________________ □ □ Reason for Visit: Nutrition Specific Health Concern Explain your health concern in detail: □ Integrated Wellness _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Transformed By the Renewing Of Your Mind Please identify the other health care providers you have seen, treatments, and results: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Any other health concerns you wish for this office to know about? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Past Medical History: (Circle all that apply) Measles Mumps Chicken Pox Trauma Oculo-motor Problems Learning Difficulties Fever Cravings Diarrhea Diabetes Weight Management Vertigo Stress Ear infections Allergies Asthma Bed Wetting Walking Difficulties Colic Anxiousness Food Sensitivities Influenza Autoimmune Lyme’s Dx AutoImmune Stomach Pain Upper Respiratory Infection Bronchitis Eczema Motion Sickness Rashes Balance Clumsy Constipation Endocrine Cancer Depression Headaches Sleep Disturbances Please add any other past history issues in the space below Discuss how circled items were managed (include treatment and outcomes): Transformed By the Renewing Of Your Mind Please identify any additional symptoms you are experiencing or have in the past. (Please circle all that apply) Fatigue Shaky with missed meals Irritability before meals Headaches with physical and mental stress Eating to relieve fatigue Weak Immune Cannot fall/stay asleep Allergies Dizziness from moving down up Slow to start in a.m. Spells of dizziness Gastric Ulcers Asthma Afternoon headaches Hemorrhoids Feeling full/bloated Varicose veins Craving sweet, caffeine, cigarettes Unstable behavior Blurred vision Frequent Urination Any Blood in Stool/Urine Frequent Bowel Movement Increase/Decrease in Precocious Symptomatology Diarrhea Energy Boosts Hard/Loose Stool Gestational Depression Irritation Mood Swings Fears Cravings Avoidances Fear of childbirth Post natal Depression Feeling tired or sluggish Feeling cold-hands, feet, all over Constipation Requires excessive amounts of sleep Weight gain despite efforts Gain weight easily Infrequent bowel movements Outer 1/3 of eyebrow thinned Thinning of hair on scalp, face, genitalia Dryness of skin and/or scalp Mental sluggishness Depression and lack of motivation Yeast Infection Thyroid Concerns Morning headaches resolving throughout the day Physiological notes: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Transformed By the Renewing Of Your Mind How was the diagnosis managed? ________________________________________________________________________ ________________________________________________________________________ Sleeping Habits (include how many hours/quality): _______________________________________________________________________ Activity Level: Number of doses of antibiotics you have taken: (List Below) During the past 6 months: _______________________________ During the course of your life: _______________________ Vaccination History: _____________________________________________________________________________ _____________________________________________________________________________ Please describe any adverse reactions to vaccinations? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Transformed By the Renewing Of Your Mind Prenatal History: Please describe any know information you have surrounding your mother’s pregnancy and delivery of you: ______________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Family History: Please describe in detail your family history. Indicate if parents or siblings experience autoimmune disorder, diabetes, cancer, heart disease, stroke, heart attack, angina, dementia, depression, gastro-intestinal dysfunction, endocrine dysfunction, mental illness, anxiety…please feel free to add any other family health issues: ______________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Diet: Describe your diet over the last 24 hours: Breakfast: ___________________________________________________________________ ____________________________________________________________________________ Lunch: ______________________________________________________________________ ____________________________________________________________________________ Dinner: _____________________________________________________________________ ____________________________________________________________________________ Transformed By the Renewing Of Your Mind Traumas: □ □ Were you ever involved in a trauma? No Yes Please describe: ______________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ □ □ Did you participate in sports as a youth? No Yes (i.e. football, soccer, gymnastics, baseball, basketball, cheerleading, martial arts, etc…) Sports: _____________________________________________________________________ Have you ever been involved in a car accident? □No □Yes Please describe: ______________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Have you ever been seen for an emergency other than a trauma? □No □Yes Please describe: _____________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Prior surgeries? □No □Yes Please describe: ____________________________________ __________________________________________________________________________ Menarche (Female patients)? □No □Yes Age: ________________ Signature of person completing this document: ____________________________________ Print Name: ________________________________________________________________ Date: __________________________ Transformed By the Renewing Of Your Mind
