INITIAL PATIENT INTAKE FORM

When completing this Patient Intake Form, please provide as much detail as you can give as the
additional information is very helpful in understanding your health.

Record all food and drink for three days prior to the visit.

Bring medical or lab reports that that are relevant and any medicines you are taking. Also, bring
your insurance card.

THIS INFORMATION IS PART OF YOUR MEDICAL RECORD, AND BY LAW, CANNOT

BE RELEASED OR DISCLOSED WITHOUT YOUR PERMISSION:

Name: _______________________________________ M/F: ___

Address: _________________________________
Telephone No. Home: ______________ Work: ______________
Birthdate: _____________ Age: _________
Weight: ______ Ideal Weight: ________ Height: ________
Insurance: __________________ Private Pay: _______________________________
Insurance No: ____________________________ GROUP NO: _____________

Other Medical or Health Providers you have seen within the last 5 years:

___________________________________________________________________

PAYMENT: Payment or insurance billing information is due at the time of initial visit. If you
need to schedule payment or are having difficulty with payment, please contact the provider.

I. MEDICAL REASON(S) FOR VISIT

What is the medical reason for your visit?

_____________________________________________________________________

How long have your had this condition?

_____________________________________________________________________

Current RX/Herbs/Homeopathic Vitamins:

_____________________________________________________________________

Significant Health Problems: In chronological order

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

ALLERGIES: (Food, MEDICATION, Environmental)

Present or Previous:
MEDICATION: ____________________________ FOOD: _________________________
ENVIRONMENT: __________________________ OTHER: ________________________

How long have your had them?

_____________________________________________________________________

What do you take for them?

_____________________________________________________________________

How do your allergies affect you?

_____________________________________________________________________

II. REVIEW OF SYSTEMS

Headaches?
Location: (front, sinus, temple, etc.
How often?
When?
What makes them better?
How makes it worse?
Intensity of pain?
Days better?
Season better?

FOR THE FOLLOWING QUESTIONS: Please check off yes or no if you have problems in the
following areas. If yes, briefly describe.

Sinus: Sinus tenderness?

Eyes? Ears?
Nose? Throat?
Teeth? Bad / sour breath?
Fillings? Mercury? Silver? Throat?
Thyroid? Chest?
Breast? Stomach?
Liver? Spleen?
Bowel Movements? How often? Consistency?
 Gas (flatus)? Rectum?
Women: Vaginal Problems? Problem with menstrual flow.
Frequency? Menstruation heavy? Light?
Contraception use? STD?
Men: Genital
Testicular Exam: Prostate:
(PSA/PAP)

OINTS: Arms: _____ Shoulder: _____

Legs Feet?

ADDITIONAL PROBLEMS:___________

III. LIFESTYLE

Stress
Stress in your life?
Your stress level? Scale of 1 - 10?

Joy
What gives you joy in life?
What gives you pleasure in life?
Do you have hobbies you enjoy?
Do you live alone or with family/friends?
Your joy level? 1 - 10?

Sleep
Any difficulty with sleep? Hours do you sleep?
Do you awaken refreshed after sleeping?

IV. FAMILY HISTORY

Significant Family History of Illness:

MOTHER: Alive:_____ Age:

FATHER: Alive _____Age:
SIBLINGS: Health: Age:

Parents: Smokers?
Alcohol or drug use in the family?
History of congenital diseases in the family?
Where are you in the birth order?
What was the environment like as a child? Peaceful? Happy? Tension? Conflicted?

Birth: Any unusual problems at birth? Premature? Other?

Vaccinations:

Significant Health Problems as a child?

Social History

Please fill out to your degree of comfort; this information is confidential and helpful.

Do you have a consistent network of family or friends you can rely on for support?

Personal use of alcohol: How often? Amt.

Personal use of marijuana, drugs or narcotics? Past? __________ Present? __________

How often? __________ Amount? __________

Tobacco use:

Sexuality: Are you involved in a satisfying relationship?

EXERCISE: What do you like to do for exercise and how often?

____________________________________________________________________

V. ENVIRONMENT

A. WORK

What kind of setting do you work in?

Home? _____ Office? _____ FACTORY? _____

Do you like your work?

If not, what would you rather do?

Any unusual problems with your work environment? Stress?

Mechanical injury (carpal Tunnel)?
At work do you get dizzy or have headaches?

Any history of work related injuries? Detail?

____________________________________________________________________

B. HOME

House? Apt? How long have you resided there? _________

Briefly describe your home? Dry :_____ Damp: _____ Moldy: _____
Sunny: _____ Dark: _____
Heating what kind? Woodstove? _____ Forced air? ______ A/C? _____
Do you live near:
Factory? _____ Dry Cleaner? _____ Incinerator? _____ Power Station? _____

Do you use an electric blanket or heating pad?

Is there an electric outlet at the head of your bed?

C. ALLERGENS

Do you own cats? Pets? Do you sleep with them?

Home clean? Thoroughly vacuumed and or mopped at least once a week?

VI. OTHER

Use additional paper as necessary. This is the fun stuff. Now that you’ve worked so hard on
completing this form, it’s time for some fun... Be as creative as you like.

Draw a picture of yourself. (You can use a separate sheet of paper.)

Mark where you hurt or have difficulties.

Draw a picture of yourself as you would like to be in the future?

If your illness or condition had a face, what would it look like?

If it had a voice, what would it say?