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Integrative Health and Wellbeing - Intake FormGENERAL INFORMATIONName: __________________________________________________ Date of Birth: __________ Reason for your visit: __________________________________________________________________________________________________________________________________________________MEDICAL HISTORYPlease check the appropriate box and list the date of onset O Current(C)or O Past condition (P)C PGastrointestinalC PGenitourinaryO OIrritable Bowel SyndromeO OKidney StonesO OGERD (acid reflux)O OFrequent Urinary InfectionO OCrohn’s DiseaseO OSexual DysfunctionO OUlcerative ColitisO OUrinary IncontinenceO OCeliac DiseaseO O Yeast InfectionO OPeptic Ulcer DiseaseInflammatory/ AutoimmuneO OHepatitisO OLupus SLECardiovascularO ORheumatoid ArthritisO OHeart AttackO OChronic Fatigue SyndromeO OHigh CholesterolO OOther ________________O OHigh Blood PressureO OStrokeRespiratoryO OHeart FailureO OAsthmaO OPacemakerO OCOPDO OHeart Valve DiseaseO OSleep ApneaEndocrineO ODiabetesSkinO OThyroid disorderO OEczemaO OInfertilityO OPsoriasisO OEating Disorder (Anorexia, Bulimia)O ODermatitisO OAcneHematology/ OncologyO ORosaceaO OAnemiaO OBleeding disorderNeurologicO OLow PlateletsO OMigraineO OCancer _________________O OAlzheimer’s DiseaseO OParkinson’s DiseasePsychiatricO OSeizuresO ODepressionO OHeadacheO OAnxietyO OMultiple SclerosisO OBipolar DisorderO ODementiaO OADHD/ ADDO OOther _____________O OPTSDOther not listed: _____________________________________________________________________Please list any surgeries Surgery DateCommentMEDICATIONS & SUPPLEMENTSPlease list all prescription and over the counter medications, herbs and supplementsName & BrandDoseFrequencyStart DateReasonALLERGIESPlease list the allergen and the type of reaction Medication: __________________ Food: _________________ Environmental: ___________SOCIAL / LIFESTYLE HISTORYHABITSHave you ever smoked cigarettes? O Yes O No If yes, how many cigarettes per day? Do you smoke currently? O Yes O Do you drink alcohol? O Yes O No How many drinks per week? _____Do you drink caffeinated beverages (Coffee, Tea, Soda)? How many per day? _____EXERCISEHow many times a week do you exercise? ____________ Describe: ____________________Please describe your fitness goalSTRESSPlease rate your current stress level on a scale of 0-10: _____________________________How do you manage your stress? __________________________________________________FAMILY HISTORYLivingDeceasedAgeIllnessMotherFatherGrandparentsSYMPTOM REVIEWPlease check all current symptoms occurring or present in the past 6 months. GENERAL ? Fever ? Weight Loss or Gain? Fatigue ? Heat or Cold Intolerance HEAD, EYES , EARS , THROAT? Ear Ringing/Buzzing ? Hearing Loss? Eye Pain or Redness? Vision problems (other than glasses) ? Bleeding gums? Nosebleed ? Bad BreatheCARDIOVASCULAR? Chest Pain ? Shortness of Breathe? Palpitations ? Leg Swelling PULMONARY? Cough ? Excessive Mucous? WheezingGASTROINTESTINAL? Abdominal Pain or Cramps? Bloating After Meals ? Blood in Stools ? Constipation ? Diarrhea ? Dry Mouth ? Excess Flatulence/Gas ? Heartburn ? Hemorrhoids ? Indigestion ? Nausea ? Vomiting Other: ______________________________GENITOURINARY? Blood in urine? Burning with urination? Pain with urination ? Frequent urination? Incontinence ? Pain during intercourse ? Decreased libidoMUSCULOSKELETAL ? Back Pain ? Joint Pain ? Joint Redness ? Joint Stiffness ? Muscle Pain ? Muscle Spasms ? Muscle Stiffness NEUROLOGICAL ? Headache ? Weakness ? Numbness or Tingling ? Trouble Walking ? Dizziness or Vertigo PSYCHOLOGICAL? Anxiety ? Depression ? Panic Attacks ? Suicidal Thoughts SKIN / NAILS/ HAIR? Rash ? Hives? Itching ? Acne? Body Odor? Brittle Nails? Nail Fungus? Hair Loss? Grey Hair Other: ______________________________WOMEN’S HEALTHAge at First Period:______ Menses Frequency:______________ Length:_____________ Last Menstrual Period:___________ O Heavy Period O Irregular Period O Cramps O PMS O Fibroids O Menstrual clots O Light Color O Dark Color Nature of pain (please indicate before, during or after menses)O Cramping_______ O Stabbing_______ O Bearing down sensation_______ O Dull________Do you use contraception?______ If yes, what type?_______________For how long______Are you Pregnant? Yes ____ No ____ Obstetric History: Check box if yes and provide number ofO Pregnancies ____________ O Caesarean __________ O Vaginal deliveries ________O Miscarriage ___________ O Abortion___________ O Number of children ___________Are you in menopause? O Yes O No Age at Menopause___________O Hot Flashes O Mood Swings O Concentration/Memory Problems O Vaginal Dryness O Decreased Libido O Weight Gain O Loss of Control of Urine O PalpitationsO Use of hormone replacement therapy. How long?______________________Please indicate areas of pain or distress-51435014033500Location of the pain: ______________________________________________________Duration: ________________________ Frequency: ____________________________Quality: O Sharp O Dull O Burning O Pressure O Cramping O Intermittent O Constant ................
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