Adult Intake. (Please print clearly) Name Date. Address. Address. Home Telephone Number. Emergency contact: Name
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1 Adult Intake (Please print clearly) Name Date Date of birth (M/D/Y) Sex M F Address Address Home Telephone Number Work _ May we leave messages relating to your visits? Y / N Which Phone Number? Emergency contact: Name Phone number Relation How did you hear about our Clinic? Please check one of the following:! Media/TV Article! Corporate Health/Wellness Event! Clinic staff! Clinic patient! Other
2 Other health care providers you are seeing: ( ) ( ) ( ) What are your health concerns, in order of importance to you: If you are female are you currently pregnant? Yes No (Please circle one) Medical History How would you describe your general state of health? Excellent Good Fair Poor Please indicate any serious conditions, illnesses or injuries and any hospitalizations, along with approximate dates.
3 Do you have any allergies (medicines, environmental, etc.)? Please list all current medications (prescription, over-the-counter, vitamins, herbs, homeopathics, etc.) Please list past prescription medications. How many times have you been treated with antibiotics? Do you frequently use any of the following? (circle) Aspirin / Laxatives / Antacids / Diet pills / Birth control pills/implants/injections Alcohol how much/day or week _ Tobacco form and amount/day Caffeine form and amount/day Recreational drugs what and how often Please indicate what immunizations you have had " DPT (diphtheria, pertussis, tetanus) " Haemophilus " Tetanus booster; when? " Hepatitis A influenza B " Flu " Hepatitis B " MMR (measles, mumps, rubella) " Polio " Smallpox Other _ Please indicate if any caused adverse reactions:
4 Do you get regular screening tests done by another doctor? (pap, blood tests, etc.)? Y / N Diet Do you have any food allergies or intolerances? Please list. Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)? Describe a typical day s diet: Breakfast Lunch _ Dinner _ Snacks _ Beverages (and total quantity) Family History Indicate if a close relative (parent, child, sibling) has had any of the following: Allergies Asthma Heart Disease High Blood Pressure Cancer Diabetes Depression Other Mental Illness Drug Abuse/Alcoholism Kidney Disease Other Please indicate which family member! I don t know my family medical history
5 Environment Occupation Hobbies Do you exercise regularly? Y / N What do you do for exercise, how much, how often? Are you exposed to significant tobacco smoke (work, home, etc.)? Y / N Are you frequently exposed to animals (work, pets, etc.)? Y / N How is your home heated? Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe. How would you describe the emotional climate of your home? How stressful is your work, or other aspects of your life? How well do you handle these stresses? Is there anything that you feel is important that has not been covered? For file use only
6 Review of Systems Name: Date: Y N P A condition you have now A condition you have NEVER had A condition you have had in the past 1. GENERAL Weight Weight 1 year ago Maximum weight When Height Fatigue/Weakness Y P N Fever/Chills Y P N 2. SKIN Rashes Y P N Eczema, hives Y P N Acne, boils Y P N Itching Y P N Color change Y P N Lumps Y P N Night sweats Y P N Dryness/Moistness Y P N Temperature Y P N Nail changes Y P N Change in mole Y P N Skin cancer Y P N 3. HEAD Headache Y P N Head injury Y P N Dizziness Y P N 4. EYES Impaired vision Y P N Glasses/Contacts Y P N Eye pain Y P N Tearing or dryness Y P N Double vision Y P N Glaucoma Y P N Cataracts Y P N Blurring Y P N Bothered by sun Y P N
7 Itching Y P N Redness Y P N Discharge Y P N Blind spot Y P N 5. EARS Impaired hearing Y P N Earache Y P N Dizziness Y P N Discharge Y P N Infections Y P N 6. NOSE and SINUSES Frequent colds Y P N Nose bleeds Y P N Stuffiness Y P N Hay fever Y P N Sinus problems Y P N 7. MOUTH and THROAT Frequent sore throat Y P N Sore tongue/mouth Y P N Gum problems Y P N Hoarseness Y P N Dental cavities Y P N Loss of taste Y P N 8. NECK Lumps Y P N Swollen glands Y P N Goiter Y P N Pain or stiffness Y P N 9. RESPIRATORY Cough Y P N Sputum Y P N Spitting up blood Y P N Wheezing Y P N Asthma Y P N Bronchitis Y P N Pneumonia Y P N Pleurisy Y P N Emphysema Y P N Difficulty breathing Y P N Pain on breathing Y P N Shortness of breath Y P N Shortness of breath at night Y P N
8 Shortness of breath lying down Y P N Tuberculosis Y P N Tuberculin Test Y P N Last Chest -ray 10. CARDIOVASCULAR Heart disease Y P N Angina Y P N High blood pressure Y P N Murmurs Y P N Rheumatic fever Y P N Chest pain Y P N Swelling in ankles Y P N Palpitations, fluttering Y P N Cyanosis Y P N Past ECG Y P N Other heart tests 11. BREASTS Do you do self exams? Y P N Lumps Y P N Pain (or tenderness) Y P N Nipple discharge Y P N 12. GASTROINTESTINAL Trouble swallowing Y P N Heartburn Y P N Change in thirst Y P N Change in appetite Y P N Nausea Y P N Vomiting Y P N Vomiting blood Y P N Bowel movements - how often? Is this a change? Y N Blood in stool Y P N Belching or passing gas Y P N Jaundice (yellow skin) Y P N Liver disease Y P N Gall bladder disease Y P N Ulcer Y P N Indigestion Y P N Diarrhea Y P N Rectal bleeding Y P N Hemorrhoids Y P N Black, tarry stool Y P N Abdominal pain Y P N Food allergy Y P N
9 Hernias Y P N 13. URINARY Pain on urination Y P N Increased frequency Y P N Frequency at night Y P N Inability to hold urine Y P N Frequent infections Y P N Kidney stones Y P N Blood in urine Y P N Urgency Y P N Hesitancy Y P N 14. MALE REPRODUCTIVE Hernias Y P N Testicular masses Y P N Testicular pain Y P N Are you sexually active? Y P N Sexual difficulties Y P N Venereal disease Y P N Discharge or sores Y P N Sexual preference: Heterosexual Y P N Bisexual Y P N Homosexual Y P N 15. FEMALE REPRODUCTIVE Age menses began Average number of days Length of cycle Bleeding between periods Y P N Are cycles regular Y P N Pain during intercourse Y P N Painful menses Y P N Excessive flow Y P N PMS Y P N Birth control? Y P N What type? Number of pregnancies Number of live births Number of miscarriages Number of abortions Difficulty conceiving Y P N Are you sexually active? Y P N Sexual difficulties Y P N Venereal Disease Y P N Sexual preference: Heterosexual Y P N
10 Bisexual Y P N Homosexual Y P N Last menstrual period Vaginal discharge Y P N Vaginal itching Y P N Last PAP - (date) 16. MUSCULOSKELETAL Joint pain or stiffness Y P N Arthritis Y P N Broken bones Y P N Muscle spasms or cramps Y P N Weakness Y P N Joint swelling Y P N Backache Y P N 17. PERIPHERAL VASCULAR Deep leg pain Y P N Cold hands/feet Y P N Varicose veins Y P N Thrombophlebitis Y P N Leg cramps Y P N Extremity numbness Y P N Extremity coldness Y P N Extremity swelling Y P N Extremity ulcers Y P N 18. NEUROLOGIC Fainting Y P N Seizures/Convulsions Y P N Paralysis Y P N Muscle weakness Y P N Numbness or tingling Y P N Loss of memory Y P N Involuntary movement Y P N Loss of balance Y P N Speech problems Y P N 19. ENDOCRINE Heat or cold intolerance Y P N Thyroid trouble Y P N Excessive thirst Y P N Excessive hunger Y P N Excessive urination Y P N Excessive sweating Y P N Diabetes Y P N Hypoglycemia Y P N
11 Hormone therapy Y P N 20. BLOOD/LYMPHATIC Anemia Y P N Easy bleeding or bruising Y P N Past transfusions Y P N Lymph node swelling Y P N 20. ALLERGIC HISTORY Drug sensitivity Y P N Reaction to vaccine Y P N Allergies? Please list 21. EMOTIONAL Depression Y P N Mood swings Y P N Anxiety or nervousness Y P N Tension Y P N Phobias Y P N Alcohol/Drug abuse Y P N Insomnia Y P N 22. HOBBIES/HABITS Please answer yes (Y) or no (N) Do you eat three meals daily? Y N What are your main interests and hobbies? Do you awake rested? Y N Do you sleep well? Y N Do you average 6-8 hours sleep? Y N Do you enjoy your work? Y N Do you watch television? Y N How many hours/day? Do you read? Y N Do you exercise? Y N What forms? How many times/week? Do you take vacations? Y N Have you been treated for drug Y N dependency? Do you use recreational drugs? Y N Do you use alcoholic beverages? Y N Have you been treated for alcoholism? Y N How often?
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