Health History Intake Form Please enable JavaScript in your browser to complete this form.NameDate of Birth *Today's DateAddressCityZipPhoneEmail *Emergency ContactPhoneRelationFor 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 conditionOther 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 themHeightWeightPast Minimum/Maximum WeightWhen?Do you have any infectious diseases?Do you have any chronic conditions?Hospitalizations / SurgeriesReason for Hospitalizations / SurgeriesWhen?Reason for Hospitalizations / SurgeriesWhen?Reason for Hospitalizations / SurgeriesWhen?Reason for Hospitalizations / SurgeriesWhen?X-Rays / CT Scans / MRIs / Special StudiesReason for X-Rays / CT Scans / MRIs / Special StudiesWhen?Reason for X-Rays / CT Scans / MRIs / Special StudiesWhen?Reason for X-Rays / CT Scans / MRIs / Special StudiesWhen?Review of Systems & SymptomsEars, Eyes, Nose, Throat (EENT) (check all that apply)Seasonal AllergiesImpaired VisionTMJ/Jaw PainChronic Ear InfectionsGlaucomaTubes in EarsMacular DegenerationDifficult to cough up or blow outImpaired HearingGlasses/ContactsConstant and/or chronicPlugged EarsDry EyesTinnitus (Ringing in Ears)Itchy earsHeadacheFrequent Sore ThroatRed EyesSinus PressureDry NoseSinus HeadacheRunny or dripping noseChronic Sinus InfectionsStuffy noseItchy EyesDeviated septumEye pain/strainTeethgrindingSkin issuesRashes/EczemaMigraine Headache?YesNoLocation of HeadacheDullSharpAchyHollowDo you experience an Aura with your migraines?YesNoPhlegm/CongestionYesNoColor of the phlegmCheck The Following:Large AmountScanty AmountThickStickyThinWateryBloodRespiratoryAsthmaShortness of BreathEmphysemaCOPDDifficulty InhalingLung CancerChronic CoughDifficulty ExhalingFrequent Colds How often?TuberculosisHistory of pneumoniaCardiovascularPalpitations/FlutteringChest painRacing HeartHeart DiseaseHigh Blood PressureHigh cholesterolStroke?YesNoWhen was the Stroke?Heart Attack?YesNoWhen was the Heart Attack?Energy / ImmunityFatigueChronic InfectionsHIV/AIDSGet sick easilyChronic Fatigue SyndromeSlow wound healingAnemiaAutoimmune Disorder?YesNoSpecify:Hep B or C?YesNoWhich type?Time of day at lowest energy:Energy Level 1-10(10 highest):Emotional/Mental HealthFeelings of anxietyFearfulnessIrritability/Easily AngeredFeelings of depressionNervousnessMood swingsWorryingBipolar DisorderAddictionPost-Traumatic Stress DisorderHistory of AbuseADD / ADHDObsessive-Compulsive DisorderHistory of Eating DisorderPanic attacks?YesNoHow often do you experience 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?SleepHours per nightTime to bedTime at wakingDo you wake rested?Trouble falling asleepAnxiety at nighttimeMuscle crampsTrouble staying asleepNight sweatsWaking feeling tiredVivid dreams or nightmaresHot flashesWaking with a headacheHeart racing, flutteringPain that wakes youFeeling hungry in middle of nightShortness of breathPain that keeps you from sleepingCoughGastrointestinalChange in appetiteDifficulty losing weightBelchingLow appetiteDifficulty gaining weightLiver DiseaseLow appetiteDifficulty gaining weightLiver DiseaseFeelings of constant hungerUlcersGallbladder DiseaseAcid reflux/GERDGallstonesBloating, fullness, distentionGasNausea/VomitingHemorrhoidsConstipationDiarrheaLoose stoolSticky stoolIncomplete stoolBurning stoolPainful bowel movementStraining during bowel movementMucus in stoolBlood in stoolUndigested food in stoolHard stoolDry stoolPebble-like stoolBulky stoolDifficulty having bowel movementsEspecially malodorous stoolCrohn’sUlcerative ColitisDiverticulitisAbdominal Pain?YesNoWhere is the location of the Pain?# of bowel movements per day# of bowel movements per weekMusculoskeletal/PainNeck/Shoulder PainLow back painLeg painUpper back painHip pain/sciaticaMid-back painArm painMuscle spasms/crampsFibromyalgiaRheumatoid ArthritisChronic painJoint pain?YesNoWhere do you experience joint pain?EndocrineHypothyroidGrave’s DiseasePre-diabetesHyperthyroidHashimoto’s ThyroiditisCold hands &/or feetNight sweatsFeeling hot or coldDiabetes?YesNoWhich Type?NeurologicVertigo/DizzinessTremorsSeizures/EpilepsyLoss of BalanceNumbness/TinglingMuscle WeaknessParkinson’s DiseasePeripheral NeuropathyParalysis?YesNoLocation of paralysis:Genito-UrinaryDifficult urinationBlood in urineUrinary incontinencePainful urinationDribbling urineFrequent urinationBurning urinationIncomplete urinationFrequent urination at nightKidney diseaseKidney stonesFrequent urinary tract infectionsReproductiveIrregular cyclesBleeding between cyclesVaginal itching or irritationAbsence of mensesDifficulty conceivingVaginal odorHeavy menstrual flowPainful intercourseClots in mensesMenstrual crampsLow libidoMenopausal SymptomsPMSFrequent vaginal infectionsVaginal drynessPelvic painVaginal dischargeBreast tendernessGenital herpesNipple dischargeHPVOvarian CystsPCOSEndometriosisLuteal phase defectLack of ovulationPelvic Inflammatory DiseaseVaginal Pain (vulvodynia)Prostate problemsGenital herpesPremature ejaculationTesticular pain/swellingDifficulty getting an erectionDifficulty ejaculatingPenile dischargeDifficulty maintaining an erectioDifficulty conceivingCancer?YesNoWhat Type of Cancer?Hysterectomy?YesNoWhen was your Hysterectomy?Age at 1st periodBirth Control, if anyLength of cycle (one period to the next)PregnanciesVaginal BirthsC-Sectionsof days of flowTerminationsMiscarriagesVBACsDate of last pap smearAre you pregnant now?How far along?Diet / Lifestyle What is a typical day in the life of your dietBreakfastLunchDinnerSnacksDrinksGlasses of water per dayAmount of caffeinated beverages per dayFood allergies/sensitivitiesFoods you craveFoods you restrictDo 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?OccupationEmployerHow 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?WebsiteSubmit
