Name Date of Birth * Address City Zip Phone Email * Emergency Contact Phone Relation For sliding scale purposes, annual family income
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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 Ears, Eyes, Nose, Throat (EENT) (check all that apply) Time of day at lowest energy: Energy Level 1-10(10 highest): 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 # of bowel movements per day # of bowel movements per week Endocrine Neurologic Genito-Urinary Reproductive 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?