Medical History Intake

Clients Information

Date of Visit

Name

First

Last

Address

City

State/Province

Zip/Postal

Phone Number

Email Address

Date of Birth

Gender

Height

Weight

Chief Concerns / Issues – List in Order of Priority – Onset, Frequency, Severity

PAST MEDICAL HISTORY

Type of Delivery: Hospital/Home

Where are you in the birth order?

Complications at birth:

Type of Birth: Viginal/C-Section

Breastfed? Yes/No

Have you ever been diagnosed with any of the following conditions?

Diagnosed with any of the following?

Hospitalizations/Surgeries

Injuries/Head Trauma/Consussion/Accidents

Allegies: Medications/Seasonal Food

Medications: Currently Prescribed

Suppliments: Vitamins/Mineral & Herbs

Past Experience with Alternative/Complementary Medicine?

FAMILY HISTORY

Personal / Social History

Home Environment / Members of Household?

Relationship status? Single/Married

Describe your job/work?

How long have you had this occupation?

Do you enjoy your work?

No

YesYes

Any potentially toxic exposures at work or home?

EXERCISE: Type & Frequency

List type & frequency of exercise

Sleep Habits

Hours of sleep per night:

Have restless leg?

Usual bedtime:

Trouble falling asleep?

Usual time you wake up:

Trouble staying asleep?

Use sleep medications. How often?

Diagnosed with sleep apnea?

Additional Habits

Cigarettes: Do you Currently smoke?/How many cigarettes per day?/If Quit Date:Cigarettes: Do you Currently smoke?/How many cigarettes per day?/If Quit Date:

Coffee: How many cups per day/Night?Coffee: How many cups per day/Night?

Tea: What kind?/Cups per day?Tea: What kind?/Cups per day?

Soda: What kind?/Sodas per day:Soda: What kind?/Sodas per day:

Alcohol: What kind? Drinks per day?Alcohol: What kind? Drinks per day?

Leisure

Television: Hours watched each day?Television: Hours watched each day?

Computer: Amount of time on tech each day?Computer: Amount of time on tech each day?

Video Games: Amount of time each day?Video Games: Amount of time each day?

Alcohol & Recreational Drugs?

Family issues, job loss, legal problems due to drinking?Family issues, job loss, legal problems due to drinking?

Recreational drugs: Type(s) of recreational drugs(s)/How often?Recreational drugs: Type(s) of recreational drugs(s)/How often?

Have you ever been treated for drug or alcohol addiction?Yes/NoHave you ever been treated for drug or alcohol addiction?Yes/No

Are you currently in any type of recovery program?Yes/NoAre you currently in any type of recovery program?Yes/No

Nutrition & Diet

On a typical day what do you eat for breakfast, lunch, dinner and snacks?

Breakfast

Lunch

Dinner

Snacks

How long has this been your routine diet?

Describe any known food sensitivities, intolerance, or allergies, symptoms:

How long have been at your current weight?

Describe any significant weight gain/loss in the past five years?

Have you ever been treated for an eating disorder?

Do you crave specific foods-Sugar or Salt?

How much water do you drink each day?

REVIEW OF SYSTEMS

Cardiovascular

High or low blood pressure (circle)

Elevated cholesterol or triglyceride levels

Heart disease

Heart palpitations

Arrhythmia (irregular heart rate)

Swelling in hands or feet

Chest pain

Numbness (where?)

Pacemaker

Respiratory

Number of bowel movements per day

Urinary System

Bladder infections

Cystitis

Kidney infections

Incontinence

Frequent urination during the day

Wake up in the nigh to urinate – how often?

Blood in urine kidney stones

Family history of kidney disease

Men: Reproductive Health

Prostate inflammation or swelling

Prostate cancer

Infertility issues

Benign prostate hypertrophy (BPH)

Pain or difficulty urinating

Venereal disease

Marijuana user

Impotence or erectile problems

Date of last Colonoscopy

Age of first period

Date of Irregular PAP test

Pregnancy

Have you ever been pregnant?

Number of live births

Number of miscarriages

Number of abortions

Health issues during pregnancy?

Currently using birth control

Type of birth control used

Are you or could you be pregnant now?

Infertility issues

Date of last PAP:

Date of last mammogram:

Date of last Colonoscopy

Peri-Menopausal/Menopausal

Are you currently having regular menstrual periods?

Hot flashes

Insomnia/sleep problems

Weight gain

Lack of libido

Vaginal dryness

Currently using hormone replacement therapy

Headaches

Heavy menstrual bleeding/flooding

Incontinence/frequent urination

Memory problems/Poor concentration

Mood swings

Depression

Fatique

Musculoskeletal

Chronic neck or back pain

Low back pain

Osteoporosis

Osteopenia

Back surgery

Osteoarthritis

Rheumatoid arthritis

Date Last DEXA

Nervous System

Depression

Anxiety attacks (Panic)

Poor memory

Difficulty concentrating

Lose your temper easily

Frequently feel overwhelmed

Ever considered or attempted suicide

Treated for OCD/Paranoia

Treated for alcohol or drug addiction

10 Minute Introduction Call (762) 233-2073

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PHONE

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Medical History Intake

Clients Information

PAST MEDICAL HISTORY

FAMILY HISTORY

Personal / Social History

EXERCISE: Type & Frequency

Sleep Habits

Additional Habits

Nutrition & Diet

REVIEW OF SYSTEMS

Thank you for taking the time to complete this form.
I look forward to partnering with you towards your path of wellness.

10 Minute Introduction Call (762) 233-2073

EMAIL

PHONE

EMAIL

PHONE