Health Evaluation Intake Form

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Health Evaluation Intake Form
Contact:
Name:
Date:
Referred by:
Address:
City:
State:
Zip:
Phone: [Note preference for voice messages with an underline.]
day
night
cell
Email:
Statistics:
Age:
Birthdate:
Gender:
Height:
Current Weight:
Ideal Weight:
Weight One Year Ago:
Blood type:
Birth Weight (if known):
Family/Living Situation:
Children:
Occupation:
Exercise/Recreation:
Health Concerns:
What are your main health concerns? Describe in detail:
How have you dealt with these concerns in the past (doctors, self-care)?
What other health practitioners are you currently seeing (name, specialty, phone #)?
List any medicine or supplements you are currently taking:
Have any other family members had similar problems (describe)?
Medical History:
Please check any of the following conditions that apply to your history and briefly
describe your symptoms, chosen treatment(s), and dates.
[ ]
Cancer
[ ]
Heart Disease
[ ]
Hepatitis
[ ]
Venereal Disease
[ ]
Diabetes
[ ]
High Blood Pressure
[ ]
High Cholesterol
[ ]
Kidney Disease
[ ]
Thyroid Disease
[ ]
Depression
[ ]
Asthma
[ ]
Allergies
[ ]
Anemia
[ ]
Chronic Yeast Infections
[ ]
Other:
Health Hazards:
How do you handle stress?
Have you been exposed to, or are you sensitive to chemicals? Exposures and sensitivities
to chemicals: Tap water, air pollution, job and home exposures, cosmetics, food and
chemical residues, Nutrasweet and medicines including aspirin, birth control, etc.
Do you have or have you had trauma — physical or emotional? If so, explain:
Lifestyle History:
Have you had periods of eating junk food, binge eating or dieting?
[List any known diet that you have been on for a significant amount of time.]
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How
many hours do you average per night?
For women: How are/were your menses? Do/did you have PMS? Painful periods?
If so, explain.
Have you experienced any yeast infections or urinary tract infections? Are they regular?
How are your moods in general? Do you experience more than you would like of
anxiety? Depression? Anger?
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of
energy. (circle one): 1 2 3 4 5 6 7 8 9 10
At what point in your life did you feel best? Why?
What percentage of your meals are home-cooked?
Dietary History, Habits, and Digestion:
What were your diet and family eating habits like growing up? (You can list typical
meals.)
Describe your diet at the onset of your health concerns:
Are there particular foods you eat (comfort foods) when you are:
1. Hungry:
2. Angry:
3. Lonely:
4. Tired:
5. Depressed:
6. Celebrating:
How are your mood and energy level affected by eating these foods (nourished or
numbing)?
Do you have any known food allergies or sensitivities?
Do you have any food preferences (please list any foods categories you do not eat, ie.
gluten, dairy)
How many times a day do you typically have a bowel movement?
What is the quality of your stools? Do you experience constipation or diarrhea?
Do you experience gas or bloating?
Do you think family and friends will be supportive of you making health and lifestyle
changes to improve your quality of life? Explain, if no.
Other:
Please describe any other information you think would be useful in helping to address
your health concern(s):
Please describe your health goals and aspirations?
The most important thing I should change about my diet to improve my health is. . .
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