Health History Intake Form

Name

Date of Birth *

Today's Date

Address

City

Zip

Phone

Email *

Emergency Contact

Phone

Relation

For sliding scale purposes, annual family income

*We ask for your e-mail because it is often the easiest way to communicate with our patients. BCA does NOT share this info with ANYONE. If you do not wish to receive our e-newsletter, please let us know. We are committed to respecting your privacy.

What is the main concern that has brought you here today?

If applicable, describe past treatment for this condition

Other health concerns? (list in order of importance)

If applicable, past treatments for this condition(s)

Please list any drugs, supplements, foods, medications, or environmental allergies or sensitivities

Please list any medications (prescribed or over the counter), vitamins or supplements you are taking, including dosage and how often you take them

Height

Weight

Past Minimum/Maximum Weight

When?

Do you have any infectious diseases?

Do you have any chronic conditions?

Hospitalizations / Surgeries

Reason for Hospitalizations / Surgeries

When?

Reason for Hospitalizations / Surgeries

When?

Reason for Hospitalizations / Surgeries

When?

Reason for Hospitalizations / Surgeries

When?

X-Rays / CT Scans / MRIs / Special Studies

Reason for X-Rays / CT Scans / MRIs / Special Studies

When?

Reason for X-Rays / CT Scans / MRIs / Special Studies

When?

Reason for X-Rays / CT Scans / MRIs / Special Studies

When?

Review of Systems & Symptoms

Migraine Headache?

Phlegm/Congestion

Stroke?

Heart Attack?

Autoimmune Disorder?

Hep B or C?

Time of day at lowest energy:

Energy Level 1-10(10 highest):

Panic attacks?

If you experience anxiety, is there a specific place in your physical body where you feel it?

Is there a particular emotion that has been dominant in your life recently?

Sleep

Hours per night

Time to bed

Time at waking

Do you wake rested?

Gastrointestinal

Abdominal Pain?

# of bowel movements per day

# of bowel movements per week

Joint pain?

Endocrine

Diabetes?

Neurologic

Paralysis?

Genito-Urinary

Reproductive

Cancer?

Hysterectomy?

Age at 1st period

Birth Control, if any

Length of cycle (one period to the next)

Pregnancies

Vaginal Births

C-Sections

of days of flow

Terminations

Miscarriages

VBACs

Date of last pap smear

Are you pregnant now?

How far along?

Diet / Lifestyle

What is a typical day in the life of your diet

Breakfast

Lunch

Dinner

Snacks

Drinks

Glasses of water per day

Amount of caffeinated beverages per day

Food allergies/sensitivities

Foods you crave

Foods you restrict

Do you drink alcohol?

What kind, how much, how often?

Do you smoke?

How much, how often?

Recreational drug use?

What kind, how much, how often?

Do you exercise?

What kind, how much, how often?

Occupation

Employer

How many hours per week do you work?

Do you enjoy your job?

Why or why not?

Interests / Hobbies?

Anything else you’d like us to know?

Message

Health History Intake Form

Hospitalizations / Surgeries

X-Rays / CT Scans / MRIs / Special Studies

Review of Systems & Symptoms

Sleep

Gastrointestinal

Endocrine

Neurologic

Genito-Urinary

Reproductive

Diet / Lifestyle

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