New Patient Intake Form

General Information
Name*
First Middle Last
Preferred Name & Title
Maiden Name(s) and/or Former Name(s)
Date of Birth*
Place of Birth*
Gender*
- Male
- Female
Any Religious Preference?
Genetic Background
- African
- European
- Native American
- Mediterranean
- Asian
- Ashkenazi
- Middle Eastern
Highest Education Level
- High School / GED
- Undergraduate
- Post Graduate
Nature of Business
Job Title
Primary Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone Number*
Home Phone Number
Work Phone Number
Other Phone Number
Email*
Emergency Contact
Name*
First Last
Relationship*
Cell Phone Number*
Home Phone Number
Work Phone Number
Other Phone Number
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referred By

Primary Pharmacy
Name
Phone
Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Compounding Pharmacy
Name
Phone
Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Any Known Allergies?

Allergies or Sensitivities to Medications, Foods, or Supplements

Medication / Supplement / Food	Reaction

Complaints & Concerns
What Do You Hope To Achieve With Us?
What Are The Top 3 Things You'd Like Us To Focus On?
#1 #2 #3
When Was The Last Time You Felt Well?
Did Something Trigger A Change In Health?
If so, what happened?
What Makes You Feel Worse?
What Makes You Feel Better?
What Types Of Treatments Have You Tried In The Past?
Describe Problem Treatment / Approach Rank Effectiveness (1-10)

Current Medications
Medication Dose Frequency Start Date (mm/yy) Reason For Use
Previous Medications (Last 10 Years)
Medication Dose Frequency Start Date (mm/yy) Reason For Use
Nutritional Supplements (Vitamins / Minerals / Herbs / Homeopathy)
Medication Dose Frequency Start Date (mm/yy) Reason For Use

Patient Birth History
Your Birth Details (select all that apply)
- Full-Term
- Premature
- Induced
- Vaginal Delivery
- C-Section Delivery
Any Pregnancy Complications?
Birth Complications?
Breastfed or Bottle Fed?
Childhood
Your Age At Introduction Of:
Solid Foods Dairy Wheat
Did you eat a lot of sugar or candy as a child?
- Yes
- No
Did you have frequent ear infections?
- Yes
- No
As a child, were you up-to-date on immunizations?
- Yes
- No
Do you feel that immunizations have had an impact on health?
- Yes
- No
If yes, please explain:
Grade School
Did you develop any food or seasonal allergies?
- Yes
- No
Did you have any serious infections or experience any trauma?
- Yes
- No
Other health issues:
High School
Did you have acne which required antibiotics?
- Yes
- No
Did you have mono?
- Yes
- No
Other health issues:
College
Other health issues:
Adulthood
Other health issues:

Gastrointestinal Medical History
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Irritable Bowel Syndrome
Gastritis or Peptic Ulcer Disease
Inflammatory Bowel Disease
GERD (reflux)
Crohn's
Ulcerative Colitis
Celiac Disease
Other
Cardiovascular Medical History
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Heart Attack
Hypertension (high blood pressure)
Other Heart Disease
Rheumatic Fever
Stroke
Mitral Valve Prolapse
Elevated Cholesterol
Arrythmia (irregular heart rate)
Other
Metabolic / Endocrine
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic Syndrome
Insulin Resitance or Pre-Diabetes
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Endocrine Problems
Polycystic Ovarian Syndrome (PCOS)
Infertility
Weight Gain
Frequent Weight Fluctuations
Bulimia
Anorexia
Binge Eating Disorder
Night Eating Syndrome
Eating Disorder (non-specific)
Other
Inflammatory / Autoimmune
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Chronic Fatigue Syndrome
Autoimmune Disease
Immune Deficiency Disease
Herpes-Genital
Immune Dysfunction
Multiple Chemical Sensitivities
Latex Allergy
Other
Cancer
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Cancer
Please explain, if applicable
Genital & Urinary Systems
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Kidney Stones
Gout
Interstitial Cystitis
Frequent Urinary Tract Infections
Frequent Yeast Infections
Erectile Dysfunction or Sexual Dysfunction
Other
Musculoskeletal / Pain
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Osteoarthritis
Fibromyalgia
Chronic Pain
Other
Respiratory Diseases
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Asthma
Bronchitis
Chronic Sinusitis
Emphysema
Pneumonia
Sleep Apnea
Tuberculosis
Other
Skin Diseases
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Eczema
Psoriasis
Acne
Other
Neurologic / Mood
For any applicable medical history below, please provide date of onset. Leave ailment blank if not applicable.
Depression
Anxiety
Bipolar Disorder
Schizophrenia
Headaches / Migraines
ADD / ADHD
Autism
Parkinson's Disease
Seizures
Other
Preventive Tests & Date of Last Test
For any applicable preventive tests below, please provide date of onset. Leave ailment blank if not applicable.
Full Physical Exam
Bone Density
Colonoscopy
Cardiac Stress Test
EBT Heart Scan
EKG
Hemoccult Test (stool test for blood)
MRI
CT Scan
Upper Endoscopy
Upper GI Series
Ultrasound
Injuries
Please list any injuries below. Leave blank if not applicable.
List Injuiries
Surgeries
Please list any surgeries below. Leave blank if not applicable.
Appendectomy
Hysterectomy +/- Ovaries
Gall Bladder
Tonsillectomy
Dental Surgery
Joint Replacement (Knee / Hip)
Heart Surgery (Bypass Valve)
Angioplasty or Stent
Pacemaker
GI Surgery
Caesarean section
Other
Blood Type
Please select your blood type
- A
- B
- AB
- O
- Unknown
Please select your Rh
- Rh+
- Rh-
- Unknown
Hospitalizations
Please list any hospitalizations below. Leave blank if not applicable.
Hospital visits / stays?
Date Reason

Women's History (if applicable)
Age At First Period
How often do you get your period?
How many days does your period last?
Has your period ever skipped? If so, for how long?
Last menstrual period
Use of hormonal contraception such as:
- Birth Control Pills
- Patch
- Nuva Ring
How long have you used hormonal contraceptives? (if applicable)
Other forms of contraception used:
- Condom
- Diaphragm
- IUD
- Partner Vasectomy
Are you in menopause?
- Yes
- No
Age at Menopause
Use of hormone replacement therapy?
Obstetric History
Are you currently pregnant?
- Yes
- No
Are you currently breastfeeding?
- Yes
- No
Pregnancies
Misscarriage
Caesarean
Abortion
Vaginal Deliveries
Living Children
Post-Partum Depression
- Yes
- No
Gestational Diabetes (Baby Over 8 Pounds)
- Yes
- No
Breastfeeding, for how long? If applicable
Child #1 Child #2 Child #3 Child #4

Smoking
Currently Smoking?
- Yes
- No
How many years?
Packs per day
Attempts to quit
Second-hand smoke exposure?
Caffeine Intake
Caffeine Intake?
- Yes
- No
Coffee cups/day
- 1
- 2 - 4
- > 4
Tea cups/day
- 1
- 2 - 4
- > 4
Caffeinated Sodas or Diet Sodas Intake
- Yes
- No
12-ounce can/bottle per day
- 1
- 2 - 4
- > 4
List favorite type (Ex: Diet Coke, Pepsi, etc.)
Rate your willingness to temporarily remove caffeine from your diet, if advised:
- Very willing
- Mostly willing
- Somewhat willing
- Not really willing
- Not at all willing
Sugar Intake
Do you have frequent sugar cravings?
- Yes
- No
How often do you eat sugary foods or beverages per week?
Do you add sweeteners (honey, maple, agave, stevia, sugar, artificial sweeteners) to your food/beverages?
- Yes
- No
Rate your willingness to temporarily remove sweeteners from your diet
- Very willing
- Mostly willing
- Somewhat willing
- Not really willing
- Not at all willing
Alcohol Intake
How many drinks currently per week?
- None
- 1 - 3
- 4 - 6
- 7 - 10
- > 10
If none, skip this section
Previous alcohol intake?
- None
- Mild
- Moderate
- High
If none, skip this section
Rate your willingness to temporarily remove alcohol from your diet
- Very willing
- Mostly willing
- Somewhat willing
- Not really willing
- Not at all willing
Drugs
Are you currently using any recreational drugs?
- Yes
- No
What type(s)?
Have you ever used IV or inhaled recreational drugs?
- Yes
- No
Please explain any drug usage
Exercise
Current Exercise Program
Rate your level of motivation for including exercise in your life?
- Low
- Medium
- High
List problems that limit activity
Psychosocial
Are you happy?
- Yes
- No
Do you feel your life has meaning and purpose?
- Yes
- No
Do you like the work you do?
- Yes
- No
Stress / Coping
Have you ever sought counseling?
- Yes
- No
Are you currently in therapy?
- Yes
- No
Please describe
Do you feel you have an excessive amount of stress in your life?
- Yes
- No
Do you feel you can easily handle the stress in your life?
- Yes
- No
Daily Stressors: Rate on scale of 1-10... 10 being the highest
Work Family Social Finances Health Other
Do you practice meditation or relaxation techniques?
- Yes
- No
If yes, how often?
Check all that apply
- Yoga
- Meditation
- Imagery
- Breathing
- Tai Chi
- Prayer
- Other
Sleep / Rest
Average number of hours you sleep per night
- > 10
- 8 - 10
- 6 - 8
- < 6
Do you have trouble sleeping?
- Yes
- No
Do you snore?
- Yes
- No
Do you use sleeping aids?
- Yes
- No
Please explain
Roles / Relationship
Marital Status
- Single
- Married
- Long-Term Partnership
- Divorced
- Gay / Lesbian
- Widow
List Children (if applicable)
Child's Name Age Gender
Who is living in household?
Name Occupation / Employment
Resources for emotional support? Check all that apply
- Spouse
- Family
- Friends
- Religious / Spiritual
- Pets
- Other
Are you satisfied with your sex life?
- Yes
- No

Patients Age 0-13: Birth History
This page is for pediatric patients, age 0-13. Please only complete this page if applicable.
Mother's Past Pregnancies
# Pregnancies # Live Births # Miscarriages
Mother's Pregnancy
Provide date if applicable, otherwise leave blank.
Difficulty getting pregnant (more than 6 months)
Infertility drugs used (please specify)
In vitro fertilization
Drink alcohol
Smoke tobacco
Take Progesterone
Take prenatal vitamins
Take antibiotics during pregnancy / labor? Please explain
Take other drugs (please specify)
Excessive vomiting, nausea (more than 3 weeks)
Have a viral infection
Have a yeast infection
Have amalgam fillings put in teeth
Have amalgam fillings removed from teeth
Number of fillings in teeth when pregnant?
Have bleeding (which months?)
Have birth problems
Group B strep infection
Use induction for labor (such as Pitocin)
Have anaesthesia - what was used?
Use oxygen during labor?
Have Rhogam, if so how many shots
Gestational Diabetes
High blood pressure (pre-eclampsia)
Have chemical exposure
Father have chemical exposure
Move to newly built house
House painted indoors
House exterminated for insects
Total weight gain during pregnancy (lbs)
Total weight loss during pregnancy
Please describe diet during pregnancy
Please describe labor
Perinatal
Pregnancy duration: X preceding the week of gestation
Please enter the total number of weeks of gestation.
Very active before birth?
- Yes
- No
Hospital?
- Yes
- No
Birthing Center?
- Yes
- No
Who are the main people who care for your child?
Their employment / occupation
Resources for emotional support?
Caregiver Info
If parents were married, when?
If separated, when?
If divorced, when?
If remarried, when?
Custody arrangements

Space for Additional Notes
Additional notes / comments

Step 1 of 14

General Information

Emergency Contact

Referred By

Primary Pharmacy

Compounding Pharmacy

Any Known Allergies?

Complaints & Concerns

Patient Birth History

Childhood

Grade School

High School

College

Adulthood

Family History

Gastrointestinal Medical History

Cardiovascular Medical History

Metabolic / Endocrine

Inflammatory / Autoimmune

Cancer

Genital & Urinary Systems

Musculoskeletal / Pain

Respiratory Diseases

Skin Diseases

Neurologic / Mood

Preventive Tests & Date of Last Test

Injuries

Surgeries

Blood Type

Hospitalizations

Travel History

Dental History

Environmental & Detoxification

Women's History (if applicable)

Obstetric History

Men's History (if applicable)

Nutrition History

Smoking

Caffeine Intake

Sugar Intake

Alcohol Intake

Drugs

Exercise

Psychosocial

Stress / Coping

Sleep / Rest

Roles / Relationship

Readiness Assessment (5=very willing, 1=not willing)

Patients Age 0-13: Birth History

Mother's Pregnancy

Perinatal

Caregiver Info

Space for Additional Notes

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