Consultation Intake Form
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Date of birth
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What would you like help with at this time?
Onset and length of symptoms:
Please list any prescription or herbal medications, supplements, homeopathics and/or over the counter medications that you are presently taking: Medication/Herb/Etc. Reason, Dosage, Frequency, How Long
When was the last time you took antibiotics?
Please bring all vitamins, herbs, supplements, and medications with you to your
appointment.
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Past Medical History:
Surgical History:
Other Hospitalizations, Accidents or Physical Traumas:
Present Weight
One Year Ago
Five Years Ago
Weight
Are you currently, or have you recently been afflicted with any of the following:
Choose one or more options
Afflictions
How do you usually get sick or experience bodily distress? (digestive, respiratory, reproductive, etc.)
How often does this happen?
Any other health conditions or allergies?
Family Medical History:
Medical condition / Family member
Describe your last 3 days’ worth of meals:
Eating Regularity
Do you eat breakfast every day?
Do you eat regular meals?
How many meals a week do you typically eat out?
How many times a week do you have:
Beef
Pork
Fish
Chips
Chicken
Soda
Fried Foods
Gluten
Eggs
Coffee
Black Tea
Soy
Sweets
Dairy
how often do you eat
What would you say is the worst thing on your diet?
Are you subject to binge eating? If so, on what types of foods?
Appetite:
Good
Fair
Poor
Do you regularly experience:
Gas or Bloating after meals?
Sour burps of Heartburn?
Do you feel tired or sluggish after meals? If so, how often?
Are you on a restricted diet? If so, please explain.
How often do you have a bowel movement?
Daily
Times per week
Irregular
What is the general consistency of your stools?
Hard
Loose
Normal
Color
Brown
Dark Brown
Grey/White
Green
Yellow
Red
Urination
Normal
Scanty
More than 5 times a day
Burning
Burning?
Strong Odor?
Dark Color?
How much water do you drink daily?
Any history of bladder or kidney infections? If so, at what age?
Do you experience any of the following, past or present:
Breast
Pain
Fibroids
Ovarian Cysts
Vaginal dryness
Difficulty getting pregnant
Hot Flashes
Pelvic Pain
Vaginal infection
Difficult menopause
Irregular menstrual cycles
No menstruation
Vaginal pain
Endometriosis
Irregular PAP
STD’s including HPV
Menstrual Cycle information:
How many days do you menstruate?
Do you have spotting before or after your period?
Clots? If yes, how many and what size are they?
Color of menstrual blood: bright red, maroon, brown
Men's Health
Do you experience frequent, painful or difficult urination?
Any reproductive or prostate issues?
Lifestyle:
Tobacco Use? If so, how much and how often?
Alcohol Use? If so, how much and how often? (copy)
Caffeine Use? If so, how much and how often? (copy) (copy)
Other Drug Use Use? If so, how much and how often? (copy) (copy) (copy)
How often do you exercise?
Daily
Weekly
Rarely
What type of exercise do you do?
What is your occupation?
Do you enjoy your work?
What activities/hobbies do you do outside of work?
Stress Level:
What would you rate your level of stress? (0 = no stress – 10 = maximum stress)
What are the major sources of stress in your life?
Who provides you support in your life?
How many hours of sleep do you get on an average night? Insomnia?
Do you usually wake up feeling rested or still tired?
How would you rate your nerves?
Good
Fair
Poor
How often do you suffer from anxiety:
Often
Sometimes
Rarely
How often do you suffer from depression:
Often
Sometimes
Rarely
Would you like to add to those responses?
Emotional:
If romantically involved, how is your relationship?
Were there any emotional traumas in your early or present life? (i.e. great loss, suicide or death of a loved one, rape, etc.)
If possible, please explain what you feel to be your most negative emotion:
When do you most feel this emotion?
Have you ever been to counseling? If so, what was the outcome for you?
What is your opinion of yourself?
Briefly describe your relationship with each of your parents:
Mom:
Dad:
How would you rate yourself: None, Some, or A lot?
Hope
Faith
Charity
Generosity
Humor
Fun
Love
Anything else you would like to add:
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