Confidential Patient Intake Form Personal Information: Name: ____________________________ Date of Birth: _____________________ Age: _______ Gender: _____ Is this same gender you were born? ____Pronouns: ______ Occupation: ____________ Address (with postal code): ____________________________________________________________ Phone: ___________________________________ Email: ___________________________________ Contacts: Physician(s) Information: Emergency Contact: Name: _________________________ Name: _________________________ Phone: _________________________ Phone: _________________________ Email: _________________________
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Confidential Patient Intake Form
Personal Information:
Name: ____________________________ Date of Birth: _____________________ Age: _______
Gender: _____ Is this same gender you were born? ____Pronouns: ______ Occupation: ____________
Address (with postal code): ____________________________________________________________
Medical Information:Health Concerns: (reason for your visit today)(Please note onset of symptoms, duration, & intensity)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current Medical History: (Please note any disability under diagnosis)
Diagnosis by GP: ________________________ Diagnosis by GP: _________________________Date of Diagnosis: ________________________ Date of Diagnosis: __________________________
Past Medical History: (please check all the apply) HIV/AIDS Addictions Allergies Amenorrhea Anemia Anorexia Anxiety Appendicitis Arteriosclerosis Asthma Autoimmune Disorder Bleeding Disorder Bronchitis Bulimia Cancer Candidiasis Cataracts Celiac Chicken Pox Chron’s Disease Chronic Fatigue Chronic Pain Depression Diabetes Type 1 Diabetes Type 2 Disordered Eating
Eczema Emphysema Endometriosis Epilepsy Fainting Fibroids Fibromyalgia Gallbladder Problems Goiter Gout Heart Disease Hepatitis A Hepatitis B Hepatitis C Hernia Herpes Simplex Virus High Blood Pressure High Cholesterol HPV Hyperglycemia Hypoglycemia IBS/IBD Jaundice Kidney Disorders Liver Disorders Low Blood Pressure
Medications/Supplementation: (Prescribed/over the counter with dosage)__________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Symptoms (Please check all that apply and onset of each)General:
Digestive Nausea Vomiting Diarrhea Loose stools Constipation No daily bowel movement Hemorrhoids Rectal pain Excessive hunger Loss of appetite Weight loss Weight gain Abdominal bloating/gas Belching Acid reflux Hiccups Stomach/abdominal pain Food sensitivities
Musculoskeletal Muscle cramps Body aches Joint pain Swollen joints Paralysis Neck and shoulder tension Hand and arm pain Foot and ankle pain Low back pain Upper back pain
Please indicate your current menstrual cycle status: Menstruating Menopausal Postmenopausal
If applicable, at what age did menopause begin? ___________Please indicate any menopause-related symptoms:
Hot flashes Night sweats
Vaginal dryness Insomnia
Mood changes Depression
If having menstruation cycles, what is your cycle length? ___________(The first day of your menstruation is considered Day 1)
How many days in duration is your menstruation? ___________Please indicate the quality of blood:
Light red Dark red
Bright red Clotted
Other ___________ Unsure
Please indicate the quanity of blood: Heavy flow Normal flow Light flow Unsure
If you experience any cramping, please indicate when? Before menstruation During menstruation After menstruation
Please indicate if you experience any of the following between periods: Vaginal discharge Bleeding Cramps/pain
How would you describe any sensations associated with your cycle? _____________________________________________________________________________________________________________________________
Do you experience breast tenderness? Y / NWhen? ________________________ Where? ________________________
Pregnancy:How many births have you had? _________________Please indicate any pregnancy-related difficulties: ____________________________________________________________________________________________________________________________________________
Are you currently pregnant? Y / NAre you trying to become pregnant? Y / N
Are you currently using contraception? Y / NIf yes, what type and for how long: _____________________________________________________________