Bella Sano
New Patient Intake Form Last name: ______________________________ First name: __________________________________________Date of birth: __________Age: ______Gender (sex): ______Email: ______________________________________Address: _________________________City: ____________State: ______Zip: __________Home phone: _____________________ May we leave a confidential message at this number? Yes ? No ?Work/cell phone: ______________________May we leave a confidential message at this number? Yes ? No ?Emergency contact: ________________Phone: _____________Relation: ______________Are you: ____Single____Married____Partnered____Separated___Divorced___WidowedDo you have children? Y / N (names and ages): _____________________________________________________Your occupation: __________________Your education: ______________________________________________How did you hear about us? ____________________________________________________________________*Email will only be used to contact you or to send you newsletters. It will not be shared with anyone.Present Health Concerns (in order of importance):Duration:1___________________________________________________________________________________________2___________________________________________________________________________________________3___________________________________________________________________________________________Please describe what you think is the cause of your health conditions:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any vitamins/herbs/supplements that you are taking:NameReason for takingDose/dayFor how long____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any prescription drugs or over-the-counter medicines that you are taking:NameReason for takingDose/dayFor how long________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies: (Please circle any which are life-threatening) ______________________________________________________________________________Are you sensitive to chemical smells? _____ Have you had repeated exposure to any chemicals, fumes, dust? (If so, please specify) _______________________________________________Medical History:Primary Care Doctor/Provider: _________________________________Date last seen: _________Doctor’s/Provider phone: ____________________________Fax: ________________________________Date of your last physical exam: ______________Results: ________________________________Date of last blood work: ____________________Results: ________________________________Date of last PAP/pelvic exam: ________________Results: ________________________________Date of last mammogram: ___________________Results: ________________________________Date of last prostate exam: __________________Results: ________________________________Date of last colonoscopy? ___________________Results: ________________________________When was your last menstrual period? _________Are you pregnant? ______How far along? _____Major Surgery: _______________________________________________________________________Are you sexually active? (Circle one) Yes / No If yes, is it with (circle one): male female bothDo you or your partner(s) use any form of contraception? Yes / No If so, what type(s)? ________Family History: Please designate which family members have had the following health conditions. M=Mother F=Father B=Brother S=Sister G=Grandparent C=ChildAllergiesDiabetesMood/Mental disorderAlcoholismCancer Neurological diseaseAnemiaEndometriosisObesityArthritis-RheumatoidHeart DiseaseSkin problemsArthritis-OsteoHigh Blood PressureStrokeAutoimmune diseaseHigh CholesterolThyroid diseaseDepressionKidney diseaseTuberculosisExercise: (Please specify what type of exercise, duration, and frequency per week)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Sleep Habits:How many hours do you sleep per night? ________Do you wake refreshed? __________________Do you have problems: falling asleep staying asleep waking up in the morningEnergy Level: (Please circle your average daily energy level)(Lowest energy) 1 2 3 4 5 6 7 8 9 10 (highest energy)Stress Level: (Please circle your average daily stress level)(Lowest stress) 1 2 3 4 5 6 7 8 9 10 (highest stress)How do you cope with stress? ______________________________________________________Review of Systems (please circle any symptoms you have experience in the last 6 months)General Skin/EENT Heart/Lung Gastrointestinal Endocrine Weight changeItchingHigh blood pressurePoor appetiteDiabetesFever/chillsRashesLow blood pressureHeartburn/GERDHypothyroidWeaknessHivesHeart palpitationsConstipationHyperthyroidFatigueEczemaHeart attackDiarrheaGoiterNight sweatsVision changesHeart diseaseGas/bloatingHypoglycemiaDizzinessDental problemsShortness of breathNausea/vomitingHot flashesMemory lossRinging in earsWheezingHemorrhoidsIncrease thirstMood changesEarachesChronic coughingUlcersHigh appetiteSleep issuesSinus infectionsStrokeBlood in stoolHair lossAnxiety/DepressionSore throatsSwollen anklesAnal discomfortWeight gainGenitourinary Musculoskeletal Female Only Male Only Other Low back painNeck pain PMSBreast lumpsAnemiaPainful urinationLow back painBreast lumpsErection difficultyOsteoporosisBlood in urineHip painHeavy mensesPain in testiclesCancerFrequent urinationFoot painHot flashesPenis dischargeFibromyalgiaNo bladder controlShoulder painPainful intercourseSores on penisCrohn’s dzNighttime urinationArm painHysterectomyInfertilityColitisBladder infectionsArthritisFibroidsLow libidoSTDsKidney infectionsTendonitisAbnormal papSwelling of testesADD/ADHDKidney stonesStrain/sprainLow libidoHerniaMood disorderRenal failureSpasm/SwellingVaginal infectionsEating disorderDiet History:How many meals do you eat per day? (Please circle) One Two Three Four or moreHow much water do you drink per day? (Please circle) None 8-24oz 24-64oz 64oz or moreCoffee: (Number of cups per day) ________ Soda (Number of cans per day) _________________Tea: (Specify type and number of cups per day) ________________________________________Please specify a typical daily diet:MealTimeFood and AmountBeveragesBreakfastSnackLunchSnackDinner Please list any food allergies that you have and the type (anaphylactic or food intolerances)________________________________________________________________________Personal Habits: (Please specify current or past usage of these substances and how much)Tobacco: _______________________________________________________________________Alcohol: _______________________________________________________________________Caffeine: _______________________________________________________________________Recreational drugs: ______________________________________________________________Digestive Health:Any stomach upset, bloating, burping, flatulence (gas), nausea, or rectal itching after food? (Please circle or specify): _______________________________________________________________________________Bowel movement frequency:(how often) _______Consistency :( hard, soft, watery, normal) ______________Do you experience constipation or diarrhea? (Please circle or specify) ______________________________Do you have blood or mucus in the stool? (Please circle or specify) ______________________________Eliminations:Do you experience pain with urination, incontinence, and other urinary symptoms?(Please circle or specify)? ________________________________________________________________Urination frequency: (how often per 24-hour period) __________________________________________Color of urine: (dark yellow, light yellow, green, colorless) __________Blood in urine? _______________Menses: (female)Are your menses regular (average every 28 days)? ______________________________________________Do you experience cramps, excessive menstrual flow, hot flashes, fibrocystic breasts, mood issues, bloating and swelling, bleeding in between menstrual cycles, other PMS issues? (Please circle or specify) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Life Balance: Wellness is a balance of many factors in life. Using the circle, please shade your level of satisfaction in each area. For example, if you are 60% satisfied with your career, shade the first 6 levels in the career slice. Do the same for each area starting from the center point radiating out.341185579375Family and Friends00Family and Friends169735579375PhysicalEnvironment00PhysicalEnvironment2840355546100016973555461000192595512255500181165582550089725576200Personal Growth00Personal Growth20402557620000204025576200001925955298450022688551441450021545552984500409765597790Career00Career238315597790002497455514350027260551193800026117555080001697355730250089725594615Fun and Recreation00Fun and Recreation409765548260Money00Money329755588900Health00Health146875588900Significant Other / Romance00Significant Other / RomanceContext of Care ReviewSuccessful health care and preventative medicine are only possible when I have a complete understanding of you physically, mentally and emotionally. Your response to the following questions will assist my understanding of your health needs. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to assist you in reaching your health goals. 1. Why did you choose to come to this clinic? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. What do you know about my approach? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. What expectations do you have from this visit? a. ___________________________________________________________________________________b. ___________________________________________________________________________________c. ___________________________________________________________________________________4. What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Rate from 0-10, 10 being 100% committed.)1 2 3 4 5 6 7 8 9 105. What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health in a positive manner?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. What behaviors or lifestyle habits do you currently engage in regularly that you believe are self-destructive? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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