Patient Intake and Health History

Please fill out the following form.

First name

Last name

Email

Phone

Date of birth

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

What brought you in to see me today?

When did this condition start?

What sort of measures have you take to improve your condition and did it help?

Health History

Please provide any hospitalizations, including reason and date.

Any serious illness, including single occurrences, recurring or chronic?

Please list any current treatments, medications, supplements and herbal remedies.

General Health

How do you rate your energy level from 0-10.

How do you rate your average stress level from 0-10

Please indicate usage of the following

Alcohol

Smoking or Vaping

Recreational drugs

Coffee

Do you exercise? what and and how much?

Do you enjoy your work? How many hours per week?

What do you "love" to do for fun?

Body Scan

Check all that apply

Pain Assessment

Please describe any acute or chronic injuries.

Are you currently experiencing pain?

yes

no

How would you rate the pain from 1-10?

Please describe the pain: sharp, burning, aching, dull.

What relieves the pain? Heat, cold, rest, exercise?

What aggravates the pain?

Mens Health History

If you are female, skip to the next section.

Have you recently had any prostate conditions?

Do you have or have you had any urinary infections or STD's

How do you define your sexual energy.

Female Health History

If you are male, you're done!

Age when your period first started?

Date of first day of last menstruation?

Usual cycle length

Is your cycle

regular

irregular /late/ too long

irregular/early/too short

irregular/ all over the map

Is your flow

light

moderate

heavy

Menses consistency

watery thin

thick

average

clotty

Ovulation

Do you have mid-cycle spotting

yes

no

Do you notice cervical fluid changes mid-cycle?

yes

no

General Women's Health History

Sexual

Is intercourse painful

Yes

No

Do you use birth control? If yes, what do you use?

Pregnancy History

Are you pregnant now?

yes

no

How many pregnancies have you had?

Please provide any additional comments or concerns.

Thank You - you are done!