Diane M. Hawk, ND, PhD
Client Intake Form
Name:__________________________________ DOB: _____________ Date:_______________
List in order of importance what your chief health concerns are:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
4. ________________________________________________
5. ________________________________________________
6. ________________________________________________
Family History: (Circle any of the following that apply)
Heart disease
High blood pressure
Heart attack
Cancer
Autoimmune disease
Osteoporosis
Asthma
Allergies
Digestive disorder
Stroke
Diabetes
Surgical History: (list reason and date for each)
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
4. ________________________________________________
Social History: (Circle any of the following that apply)
Smoke
Packs per day______
Number of years______ Coffee
Alcohol Drinks per day______ Alcohol addiction
Soda
Antacids, Analgesics, Laxatives, Trips out of the country
Cups per day______
Cups per day______
Allergies: (List any allergies to medications or herbs)
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
List all Prescription Medicines & Nutrient Supplement/Herbs that you are taking and include
dosage:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
4. ________________________________________________
5. ________________________________________________
6. ________________________________________________
7. ________________________________________________
8. ________________________________________________
9. ________________________________________________
10. _______________________________________________
Present Weight:__________
Weight one year ago:__________ Height:__________
- Over -
Review of Systems:
(Circle any of the following conditions that you have suffered from)
Skin:
Rash, Hives, Psoriasis, Eczema, Itchy, Warts, Moles, Dry, Lumps, Color changes, Cancer
Head:
Headache, Migraine, Head injury, Hair loss, Dandruff
Nose:
Frequent colds, Nosebleeds, Congestion, Post nasal drip, Polyps, Seasonal allergies
Eyes:
Blurry vision, Double vision, Cataracts, Glaucoma, Styes, Strain, Discharge, Itchy
Mouth/Throat:
Canker sores, Cold sores, Sore throat, Gum disease, Dentures, Cavities, Loss of taste, Hoarseness
Neck:
Stiffness, Swollen glands, Tension, Restricted movement
Respiratory:
Cough, TB, Bronchitis, Pneumonia, Asthma, Wheezing, Painful breathing, Shortness of breath
Cardiovascular:
High blood pressure, Low blood pressure, Murmurs, Palpitations, Arrhythmias, Edema, Chest pain
Rheumatic/Scarlet fever
Urinary Tract:
Incontinence, Pain w/ urination, Frequent infections, Urgency, Kidney stones, Discharge/blood
Gastrointestinal:
Heartburn, Indigestion, Bloating, Gas, Diarrhea, Constipation, Nausea, Vomiting, Hemorrhoids,
Ulcer, Liver disease, Gall Bladder disease, Pancreatitis, Change in appetite, Recent change in BM
Bowel Movement Frequency:______________________________________
Musculoskeletal:
Weakness, Stiffness, Arthritis, Leg cramps, Tremors, Pain
Nervous:
Paralysis, Numbness, Tingling, Sciatica, Seizures, Fainting, Carpal tunnel
Mental/Emotional:
Depression, Anger/Irritability, Suicidal, Tense/high-strung, Anxiety, Fear/panic, Eating disorder
Female Genitalia
Age Period Began:______, How Often Period Occurs:______, How long period lasts:_______
Heavy menstrual bleeding, Menstrual cramping, Menstrual Pain, PMS, Food cravings,
Poor libido, Dry vagina, Pain w/ Intercourse, Vaginitis, STD, Use of hormones:______________,
Times Pregnant:______, How many births______, Miscarriages:______, Abortions:______,
Last Pap Smear:____________, Abnormal paps, When was abnormal:_________________,
Menopausal since what age:___________, Mammography____________, Dexa Scan___________
Male Genitalia
Testicular pain/swelling, Hernia, STD, Discharge, Prostate Disease, Impotency
Exercise
How often do you exercise?_________________ What type of exercise? ______________
Sleep
Hours per night______, Nightmares, Wake Refreshed, Nap during the day, Sleep walk, Grind teeth,
Snore, If you wake up frequently, what is the reason? ____________________
Toxin Exposure
Refinery, Pesticides, Leaded paint, Solvents, Fumes, Mercury fillings, Other:______________
Sensitive to perfumes, gasoline or other vapors, Health problems when you put in new carpeting or painted