Adult Intake Form

Center for Holistic Medicine

Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will help us formulate a treatment plan.

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip:

Home Phone:

Birth Date:

Age:

Work Phone:

Cell Phone:

Place of Birth (city and state; provide country if outside U.S.):

Occupation:

Height:

Weight:

Referred by:

Today's Date:

Please check appropriate box(es):

African-American Hispanic Mediterranean Asian Native American Caucasian Northern European Other

Please list current problems in order of priority, and fill in the other boxes as completely as possible:

Describe Problem:

Mild/Moderate/Severe:

Treatment Approach:

Success:

Describe Problem:

Mild/Moderate/Severe:

Treatment Approach:

Success:

Describe Problem:

Mild/Moderate/Severe:

Treatment Approach:

Success:

With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister:

Do you have any pets or farm animals?

Yes No

If yes, where do they live?

Indoor Outdoor Both indoor and outdoor

Have you lived or traveled outside of the United States?

Yes No

If so, when and where?

Have you or your family recently experienced any major life changes?

Yes No

If yes, please comment:

Have you experienced any major losses in life?

Yes No

If so, please comment:

How important is religion (or spirituality) for you and your family’s life?

Not all Important Somewhat Important Extremely Important

How much time have you lost from work or school in the past year?

0-2 Days 3-4 Days More than 15 Days

Previous Jobs:

Unfortunately, abuse and violence of all kinds (verbal, emotional, physical, and sexual) are leading contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes.

Please do your best to answer the following questions:

Did you feel safe growing up?

Yes No?

Have you been involved in abusive relationships in your life?

Yes No

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?

Yes No

Do you currently feel safe in your home?

Yes No

Do you feel safe, respected, and valued in your current relationship?

Yes No

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?

Yes No

Would you feel safer discussing any of these issues privately?

Yes No

Past Medical and Surgical History

Illnesses

a. Anemia

When:

Comments:

b. Arthritis

When:

Comments:

c. Asthma

When:

Comments:

d. Bronchitis

When:

Comments:

e. Cancer

When:

Comments:

f. Chronic Fatigue Syndrome

When:

Comments:

g. Crohn’s Disease or Ulcerative Colitis

When:

Comments:

h. Diabetes

When:

Comments:

i. Emphysema

When:

Comments:

j. Epilepsy, Convulsions, or Seizures

When:

Comments:

k. Gallstones

When:

Comments:

l. Gout

When:

Comments:

m. Heart Attack/Angina

When:

Comments:

n. Heart Failure

When:

Comments:

o. Hepatitis

When:

Comments:

p. High Blood Fats (cholesterol, triglycerides)

When:

Comments:

q. High Blood Pressure (hypertension)

When:

Comments:

r. Irritable Bowel

When:

Comments:

s. Kidney Stones

When:

Comments:

t. Mononucleosis

When:

Comments:

u. Pneumonia

When:

Comments:

v. Rheumatic Fever

When:

Comments:

w. Sinusitis

When:

Comments:

x. Sleep Apnea

When:

Comments:

y. Stroke

When:

Comments:

z. Thyroid Disease

When:

Comments:

aa. Other (describe)

When:

Comments:

Injuries

a. Back Injury

When:

Comments:

b. Broken Bone (describe)

When:

Comments:

c. Head Injury

When:

Comments:

d. Neck Injury

When:

Comments:

e. Other (describe)

When:

Comments:

Diagnostic Studies

a. Barium Enema

When:

Comments:

b. Bone Scan

When:

Comments:

c. CAT Scan of Abdomen

When:

Comments:

d. CAT Scan of Brain

When:

Comments:

f. Chest X-ray

When:

Comments:

g. Colonoscopy

When:

Comments:

h. EKG

When:

Comments:

i. Liver Scan

When:

Comments:

j. Neck X-ray

When:

Comments:

k. NMR/MRI

When:

Comments:

l. Sigmoidoscopy

When:

Comments:

m. Upper GI Series

When:

Comments:

n. Other (describe)

When:

Comments:

Operations

a. Appendectomy

When:

Comments:

b. Dental Surgery

When:

Comments:

c. Gallbladder

When:

Comments:

d. Hernia

When:

Comments:

e. Hysterectomy

When:

Comments:

f. Tonsillectomy

When:

Comments:

g. Other (describe)

When:

Comments:

h. Other (describe)

When:

Comments:

Hospitalizations

Where Hospitalized

When:

For what reason:

When:

For what reason:

When:

For what reason:

When:

For what reason:

When:

For what reason:

How often have you have taken antibiotics?

Infant/Child

Less than 5 times

More than 5 times

Teen

Less than 5 times

More than 5 times

Adult

Less than 5 times

More than 5 times

How often have you have taken oral steroids (e.g., cortisone, prednisone, etc.)?

Infant/Child

Less than 5 times

More than 5 times

Teen

Less than 5 times

More than 5 times

Adult

Less than 5 times

More than 5 times

What medications are you taking now? Include nonprescription drugs.

Medication Name

Date Started

Dosage

Date Started

Dosage

Date Started

Dosage

Date Started

Dosage

Date Started

Dosage

Are you allergic to any medications?

Yes No

If yes, please list:

List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate dosage in mg or IU and the form (e.g., calcium carbonate vs. calcium lactate) when possible.

Vitamin/Mineral/Supplement Name

Date Started

Dosage

Date Started

Dosage

Date Started

Dosage

Date Started

Dosage

Date Started

Dosage

Infancy/Childhood:

Question

a. Were you a full-term baby?

Yes No Don't know

Comments:

a1. A preemie?

Yes No Don't know

Comments:

b. Were you breast-fed?

Yes No Don't know

Comments:

b1. Bottle-fed

Yes No Don't know

Comments:

c. As a child, did you eat a lot of sugar and/or candy?

Yes No Don't know

Comments:

As a child, were there any foods that you had to avoid because they gave you symptoms?

Yes No

If yes, please name the food and symptom (Example: milk – gas and diarrhea):

Place a check mark next to each food/drink that is part of your current diet.

List Here:

List here:

How much of the following do you consume each week?

a. Candy

b. Cheese

c. Chocolate

d. Cups of coffee containing caffeine

e. Cups of decaffeinated coffee or tea

g. Cups of tea containing caffeine

h. Diet sodas

f. Cups of hot chocolate

i. Ice cream

k. Slices of white bread (rolls/bagels)

j. Salty foods

l. Sodas with caffeine

m. Sodas without caffeine

Are you on a special diet?

Yes No

Vegetarian

Diabetic

Dairy Restricted

Blood Type

Other

Describe Here:

Is there anything special about your diet that we should know?

Yes No

If yes, please explain:

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?

Yes No

If yes, are these symptoms associated with any particular food or supplement(s)?

Yes No

If yes, please name the food or supplement and symptom(s) (Example: milk – gas and diarrhea):

Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.?

Yes No

Do you feel much worse when you eat a lot of :

High-fat foods

High-protein foods

High-carbohydrate foods(breads,pastas,potatoes)

Refined Sugar(Junk Food)

Fried Foods

1 or 2 alcoholic drinks

Other:

If other, Please specify here:

Do you feel much better when you eat a lot of :

High-fat foods

High-protein foods

High-carbohydrate foods(bread, pastas, potatoes)

Refined Sugar

Fried Foods

1 or 2 alcoholic drinks

Other:

If other, Please specify here:

Does skipping a meal greatly affect your symptoms?

Yes No

Have you ever had a food that you craved or really “binged” on over a period of time? Food craving may be an indicator that you may be allergic to that food.

Yes No

If yes, what food(s)?

Do you have an aversion to certain foods?

Yes No

If yes, what foods?

Please fill in the chart below with information about your bowel movements:

a. Frequency

More than 3x/day

1–3x/day

4–6x/week

2–3x/week

1 or fewer x/week

b. Consistency

Soft and well formed

Often Float

Difficult to pass

Diarrhea

Thin, long or narrow

Small and hard

Loose but not watery

Alternating between hard and loose/watery

c. Color

Medium brown consistently

Very dark or black

Greenish

Blood is visible

Varies a lot

Dark brown consistently

Yellow, Light brown

Greasy, Shiny appearance

Intestinal gas:

Daily

Occasionally

Excessive

Present with pain

Foul Smelling

Little Odor

Have you ever used alcohol?

Yes No

If yes, how often do you now drink alcohol?

No longer drinking alcohol

Average 1–3 drinks/week

Average 4–6 drinks/week

Average 7–10 drinks/week

Average more than 10 drinks/week

Have you ever had a problem with alcohol?

Yes No

If yes, please indicate time period (Month/Year):

From:

To:

Have you ever used recreational drugs?

Yes No

Have you ever used tobacco?

Yes No

If yes, number of years as a nicotine user:

Amount per day:

Year quit:

What type of nicotine have you used?

Cigarrette

Cigar

Smokeless

Pipe

Patch/Gum

Are you exposed to secondhand smoke regularly?

Yes No

Do you have mercury amalgam fillings?

Yes No

Do you have any artificial joints or implants?

Yes No

. Do you feel worse at certain times of the year?

Yes No

If yes, when?

Spring

Summer

Fall

Winter

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

Yes No

If yes, which one(s)?

Lead

Arsenic

Aluminum

Cadmium

Mercury

Do odors affect you?

Yes No