New Patient Intake Form

IMPORTANT - PLEASE COMPLETE THE FORM BELOW AND SUBMIT IT ONLINE BEFORE YOUR APPOINTMENT.

CALL BEFORE FAXING

EMPLOYMENT STATUS:

full time part time school retired unemployed

RELATIONSHIP STATUS:

REGULAR PHYSICAL EXERCISE?

yes no

EMERGENCY CONTACT:

CANCER INFORMATION

HAVE YOU EVER BEEN DIAGNOSED WITH CANCER, A MASS OR TUMOR?

yes no

CONVENTIONAL TREATMENT HISTORY

CURRENT/RECENT HEALTH CARE PROVIDERS (Surgery, Oncology, Primary Care Providers, etc.)

ACCIDENTS/INJURIES (briefly describe):

FAMILY HISTORY
Please include any of the following: alcoholism, high blood pressure, cancer, diabetes, heart disease, osteoporosis, other addiction or illness.

MEMBER

LIVING?

AGE

IMPORTANT DISEASES

CAUSE OF DEATH

AGE

MOTHER

FATHER

SIBLING

*MGM

*MGF

*PGM

*PGF

*M = Maternal *P = Paternal *GM = Grandmother *GF = Grandfather

SKIN

dry oily normal

PLEASE RATE THE FOLLOWING ON A SCALE OF 1 TO 10 (10 BEING THE BEST). AND WRITE IN ANY COMMENTS:

SLEEP:

ENERGY LEVEL:

APPETITE:

DIGESTION:

ANY GAS, BLOATING OR OTHER DISCOMFORT AFTER EATING?

YES NO

STOOLS:

float sink daily bad odor no odor blood in stool

DO YOU RELY ON ANY OF THE FOLLOWING FOR BOWEL ELIMINATION?

yes no

enemas laxatives purgatives

PERSONAL

HOW DO YOU FEEL ABOUT THE FOLLOWING AREAS OF YOUR LIFE?
Please choose appropriate descriptions and make any comments you would like to.

SELF

GREAT GOOD FAIR POOR

WORK

GREAT GOOD FAIR POOR

PARTNER

GREAT GOOD FAIR POOR

SEX

GREAT GOOD FAIR POOR

FAMILY

GREAT GOOD FAIR POOR

DIET

GREAT GOOD FAIR POOR

EXERCISE

GREAT GOOD FAIR POOR

PERSONAL STRESS

PLEASE RATE YOUR STRESS LEVEL ON A SCALE OF 0 TO 10 (10 BEING THE MOST), AND WRITE IN ANY COMMENTS.

STRESS LEVEL:

1. I WORRY A GREAT DEAL

YES NO

2. I FEEL LONELY

YES NO

3. I AM BORED WITH MY LIFE

YES NO

4. I THINK A LOT ABOUT DYING

YES NO

5. I HAVE PARTICULAR CONCERNS RELATING TO MY RELIGION

YES NO

6. I FEEL FEARFUL OR AFRAID

YES NO

7. I FEEL NERVOUS MOST OF THE TIME

YES NO

8. I OFTEN FEEL DEPRESSED

YES NO

9. I FEEL ANXIOUS OFTEN

YES NO

10. I AM ILL FREQUENTLY

YES NO

11. I SOMETIMES FEEL WEAK OR LIGHT-HEADED

YES NO

12. I OFTEN HAVE PAINS IN MY SHOULDERS, NECK OR BACK

YES NO

13. I OFTEN FEEL LIKE CRYING

YES NO

14. I LOSE MY TEMPER MORE THAN I USED TO

YES NO

15, OTHER PERSONAL CONCERNS

YES NO

DIET AND NUTRITION

SAMPLE OF DAY'S MENU:

TO THE BEST OF YOUR KNOWLEDGE, HAVE YOU EVER BEEN EXPOSED TO PESTICIDES, TOXIC CHEMICALS, HEAVY METALS, RADIATION OR OTHER TOXINS BEYOND THOSE ENCOUNTERED IN DAILY LIFE?

YES NO

CURRENT DIETARY SUPPLEMENTS & HERBS

AGENT

NAME

BRAND/PRODUCT NAME

DOSE

POTENCY
(mg or IU, etc,)

FREQUENCY

PRESCRIPTION MEDICATIONS

Please list all prescriptions and over-the-counter medications you are currently using (except chemo and radiation)

NAME

WHAT IT'S FOR

FOR HOW LONG?

STRENGTH

DOSE

FREQUENCY

ALLERGIES

MEDICAL HISTORY

Medical history (for example, heart disease, diabetes, high blood pressure, high cholesterol, bowel problems, autoimmune disorders such as thyroid and musculoskeletal issues, such as arthritis). Please include those here:

HOSPITALIZATION/SURGERY (NON-CANCER)

DATE

HOSPITAL

DIAGNOSIS/OPERATION

DOCTOR

PAIN

DO YOU HAVE ANY PAIN(S)?

YES NO

AREA OF PAIN

DESCRIPTION OF PAIN

PAIN LEVEL
(0 to 10)

FREQUENCY

FOR WOMEN ONLY!

MENSTRUAL PERIODS
Please complete this section to the best of your ability even if you no longer menstruate. It provides valuable information for an accurate assessment.

light heavy

HISTORY
Mark the following: 1 - IF CURRENT, 2 - IF PAST

PREGNANCY/BIRTH CONTROL

MENOPAUSE

PLEASE SUBMIT THE NEW PATIENT INTAKE FORM