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new adult patients intake form
For all new patients, please fill out this form to the best of your ability. It will help to assess your present health and will assist in facilitating the healing process.
intake form - adults
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Indicates required field
Name
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First
Last
Date
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone 905-555-5555
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Mobile 647-555-5555
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May we leave messages relating to your visits?
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Yes
No
Date of Birth (MM/DD/YY)
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Age
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Sex
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Male
Female
Weight
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Height
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Ethnicity
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Marital Status
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Married
Separated
Divorced
Widowed
Single
Other
Occupation
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Occupation status
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Full time
Part time
Retired
Student
Emergency Contact:
Name
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Relation
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Phone Number
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Name
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Relation
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Phone Number
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How did you hear about our clinic?
comment
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Referred by:
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Names of other health care practitioners (medical doctor, chiropractor, specialist, physiotherapist, etc.) you are seeing:
Name
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Practitioner:
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Name
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Practitioner:
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Name
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Practitioner:
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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CHIEF HEALTH CONCERNS
Please describe your primary health concern below:
Comment
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LIST OTHER HEALTH CONCERNS IN ORDER OF IMPORTANCE TO YOU BELOW:
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MEDICAL HISTORY
Describe your present general state of health:
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Please indicate any serious conditions, illnesses, infections, injuries, and any surgeries or hospitalizations (provide approximate dates):
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List any allergies (medicines, environmental, food, etc.) you have:
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List all names of
prescribed medication
currently being taken. Include dosage, frequency, how long you have been taking it, and any adverse reactions/allergies to medications:
Medication
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Medication
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Medication
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Dose (i.e. mg)
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Dose (i.e. mg)
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Dose (i.e. mg)
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Taken Since (How Long)
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Frequency (times/day)
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Taken Since (How Long)
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Frequency (times/day)
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Taken Since (How Long)
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Frequency (times/day)
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Adverse Reactions/ Allergies (describe)
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Adverse Reactions/ Allergies (describe)
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Adverse Reactions/ Allergies (describe)
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How many times have you been treated with antibiotics?
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Number of steroid type drugs used during the last year:
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Number of root canals:
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List all over the counter medication that you take (e.g. Aspirin, Tylenol, Tums, etc.). Include dosage and frequency and any adverse reactions/allergies to medications:
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List all vitamins, minerals, botanical (herbal) medicines, Asian medicines (Chinese Patent drugs), or homeopathic remedies that you are currently taking. Indicate daily dosage:
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Do you use any recreational drugs? Y/N (If yes, indicate what type and frequency of usage):
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Do you have regular screening tests done by another doctor? Y/N (blood tests, Pap smear, prostate exam, etc.)
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YES
NO
When was your last physical exam?
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Indicate the vaccinations have you received:
[object Object]
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Chicken pox (Varicella)
Cholera
DTP (Diphtheria/Tetanus/Pertussis)
Hepatitis A
Hepatitis B
Influenza (flu shot)
MMR(Measles/Mumps/Rubella)
Meningococcal (meningitis)
[object Object]
*
Pneumococcal
Polio
TravelVaccinations
Rabies
Typhoid
BCG (Tuberculosis)
Yellow Fever
Don’t know
Have you ever experienced any adverse reactions to the above vaccinations? Y/N (Describe):
*
PREVIOUS HEALTH HISTORY/FAMILY HISTORY
Please indicate any significant medical conditions present in your family - alive or deceased (e.g. heart disease, stroke, mental illness, thyroid conditions, cancer, diabetes, etc.) and specify which member of your family you are referring to:
Mothers's Side
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Father's Side
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Siblings
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LIFESTYLE
Please list what you have had to drink and eat in the past 24 hours:
Breakfast
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Lunch
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Dinner
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Snacks
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Beverages
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Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)?
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YES
NO
If yes, please describe
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Number of glasses of water or natural fruit juice per day:
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Percentage of fat in your diet (i.e. processed/junk foods, fried, dairy, meat fats):
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Number of sugar products/day on average (i.e. soft drinks, ice cream, cookie, sugar in coffee etc.)
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Do you drink alcohol?
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YES
NO
(If yes, indicate what type of alcohol and how many glasses per week):
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Do you smoke?
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YES
NO
(If yes, indicate for how long, and how many cigarettes/cigars per day):
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Do you drink caffeinated beverages?
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YES
NO
(If yes, indicate what type and how much per day):
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On average, how many hours of sleep do you get per night?
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On average, how many hours do you work each day?
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What level of personal stress have you been experiencing within the last 2 weeks?
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0 1 2 (minimal)
3 4 5 (average)
6 7 8 (considerable)
9 10 (unbearable)
Do you exercise?
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YES
NO
(Indicate what type of exercise, how long, how often):
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If you desire to lose weight, how much would you like to lose?
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List your hobbies
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Are you sexually active?
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YES
NO
Method of contraception:
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If you are a female are you:
Pregnant?
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YES
NO
Lactating?
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YES
NO
How much do you agree with this statement: “I am responsible for my body” (1 being least, 10 being most):
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1
2
3
4
5
6
7
8
9
10 (most)
ENVIRONMENT
Number of extreme toxic exposures/year (includes radiation, insecticides, chemicals)
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Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe:
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Areyouexposedtosignificanttobaccosmoke(work,home,etc.)?
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YES
NO
Are you frequently exposed to animals (work, pets, etc.)?
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YES
NO
(Indicate what type):
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How is your home heated?
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How would you describe the emotional climate of your home?
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How stressful is your work, or other aspects of your life? How well do you handle these stresses?
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What is/are your major stressor(s)?
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financial
job related
relationship
personal health
familymembers
family issues (i.e. death)
interpersonal
spiritual
other
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Is there anything that you feel is important that has not been covered?
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REVIEW OF SYSTEMS
Please select ‘Yes, No or Past’ if you are currently experiencing the condition. Write comments as
necessary in the space provided.
skin
Itching
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Select One
YES
NO
PAST
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Comments
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Comments
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Comments
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Comments
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Comments
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Comments
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Comments
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Comments
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Comments
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Comments
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HEAD
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eyes
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ears
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nose
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Submit
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