Intake Form

I - General Information

Date _________________

Name___________________________________________ Sex M F

Address_____________________________________________________________________

City _______________________________ State_ Zip____________

Telephone ( ) _ Work Phone ( ) ________

Cell Phone ( ) _______________________________

Date of Birth__________________________

Occupation___________________________

Marital Status: Single ___ Married Widow(er)_ Divorced____________

Emergency contact information: Name__ Telephone ( ) _

Are you currently under a physician’s care? For what reason? _______________

Family Physician______________________________________________________________

Address_____________________________________________________________________

Telephone ( ) _____________________________________________________________

List all prescription medication you are currently taking:_______________________________

____________________________________________________________________________

List all non-prescription medication you are currently taking: ___________________________

____________________________________________________________________________

Are you under the care of any other type of health care worker? _________________________

If so, please list name and phone number ___________________________________________

How long have you been treated? _________________________________________________

II. Treatment Focus

Who referred you to this office? __________________________________________________

What is your chief concern? _____________________________________________________

What are your goals for your health? _______________________________________________

List current symptoms or problems.________________________________________________

III. Review Of Symptoms

Place an (X) next to any problems you currently have and a (P) next to problems you have had in the past.

___muscle cramps	___ insomnia	___ fatigue	___ sinus pressure	___ cold hands/feet
___sciatic	__ heart palpitations	__difficult digestion	___ skin conditions	___ bone injuries
___ headaches	__ heart disease	___diarrhea	___constipation	___ osteoporosis
___ high or low blood pressure	___ anxiety	___vericose veins	___ asthma	___ disc problems
___ vision problems	___ anemia	___ diabetes	___ frequent colds and/or flu	___ neck pain

IV. Medical History

Do you have allergies? If so, to what? _____________________________________________

Recent Surgery? Describe: ______________________________________________________

Menstrual Problems? Clotting, Heavy/Light Flow, Irregularity, PMS, Spotting, Cramps: (Circle any that apply).

Is there any possibility of being pregnant? If so, in what week? _________

Muscle Tension? Indicate where:

I - General Information

Date _________________

Name___________________________________________________ Sex M______ F______

Address_____________________________________________________________________

City _____________________________________ State___________ Zip________________

Telephone ( ) _________________ Work Phone ( ) ________________________

Cell Phone ( ) _______________________________

Date of Birth__________________________

Occupation___________________________

Marital Status: Single _______ Married ________ Widow(er)_______ Divorced______________

Emergency contact information: Name________________ Telephone ( ) _______________

Are you currently under a physician’s care?______ For what reason? _____________________

Family Physician______________________________________________________________

Address_____________________________________________________________________

Telephone ( ) _____________________________________________________________

List all prescription medication you are currently taking:_______________________________

____________________________________________________________________________

List all non-prescription medication you are currently taking: ___________________________

____________________________________________________________________________

Are you under the care of any other type of health care worker? _________________________

If so, please list name and phone number ___________________________________________

How long have you been treated? _________________________________________________

II. Treatment Focus

Who referred you to this office? __________________________________________________

What is your chief concern? _____________________________________________________

What are your goals for your health? _______________________________________________

List current symptoms or problems.________________________________________________

III. Review Of Symptoms

Place an (X) next to any problems you currently have and a (P) next to problems you have had in the past.

___muscle cramps

___ insomnia

___ fatigue

___ sinus pressure

___ cold hands/feet

___sciatic

__ heart palpitations

__difficult digestion

___ skin conditions

___ bone injuries

___ headaches

__ heart disease

___diarrhea

___constipation

___ osteoporosis

___ high or low blood pressure

___ anxiety

___vericose veins

___ asthma

___ disc problems

___ vision problems

___ anemia

___ diabetes

___ frequent colds and/or flu

___ neck pain

IV. Medical History

Do you have allergies? If so, to what? _____________________________________________

Recent Surgery? Describe: ______________________________________________________

Menstrual Problems? Clotting, Heavy/Light Flow, Irregularity, PMS, Spotting, Cramps: (Circle any that apply).

Is there any possibility of being pregnant? If so, in what week? _________

Muscle Tension? Indicate where:

Name___________________________________________ Sex M F

City _______________________________ State_ Zip____________

Telephone ( ) _ Work Phone ( ) ________

Marital Status: Single ___ Married Widow(er)_ Divorced____________

Emergency contact information: Name__ Telephone ( ) _

Are you currently under a physician’s care? For what reason? _______________