Adult Intake Form

Please correct the errors described below.

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.

Please check appropriate box(es):

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

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:

Past Medical and Surgical History

Illnesses

a. Anemia

b. Arthritis

c. Asthma

d. Bronchitis

e. Cancer

f. Chronic Fatigue Syndrome

g. Crohn’s Disease or Ulcerative Colitis

h. Diabetes

i. Emphysema

j. Epilepsy, Convulsions, or Seizures

k. Gallstones

l. Gout

m. Heart Attack/Angina

n. Heart Failure

o. Hepatitis

p. High Blood Fats (cholesterol, triglycerides)

q. High Blood Pressure (hypertension)

r. Irritable Bowel

s. Kidney Stones

t. Mononucleosis

u. Pneumonia

v. Rheumatic Fever

w. Sinusitis

x. Sleep Apnea

y. Stroke

z. Thyroid Disease

aa. Other (describe)

Injuries

a. Back Injury

b. Broken Bone (describe)

c. Head Injury

d. Neck Injury

e. Other (describe)

Diagnostic Studies

a. Barium Enema

b. Bone Scan

c. CAT Scan of Abdomen

d. CAT Scan of Brain

f. Chest X-ray

g. Colonoscopy

h. EKG

i. Liver Scan

j. Neck X-ray

k. NMR/MRI

l. Sigmoidoscopy

m. Upper GI Series

n. Other (describe)

Operations

a. Appendectomy

b. Dental Surgery

c. Gallbladder

d. Hernia

e. Hysterectomy

f. Tonsillectomy

g. Other (describe)

h. Other (describe)

Hospitalizations

Where Hospitalized

How often have you have taken antibiotics?

Infant/Child

Teen

Adult

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

Infant/Child

Teen

Adult

What medications are you taking now? Include nonprescription drugs.

Medication Name

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

Infancy/Childhood:

Question

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

How much of the following do you consume each week?

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

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

How well have things been going for you?

If previously,

For Women Only:

Place a check mark by each symptom that occurs now or that has occurred in the past 6 months

General

Head, Eyes & Ears

Musculoskeletal

Mood / Nerves

Eating

Digestion

Skin Problems

Skin, Itching

Skin, Dryness

Lymph Nodes

Nails

Respiratory

Cardiovascular

Urinary

Male Reproductive

Female Reproductive

3-Day Diet Diary

Instructions for Completing the Diet Diary

It is important to keep an accurate record of your usual food and beverage intake as a part of this study. Please complete this 3-Day Diet Diary for 3 consecutive days with 1 day being a weekend day.

  • Record information as soon as possible after the food has been consumed.
  • Do not change your eating behavior at this time unless your doctor advises you to. The purpose of this food record is to analyze your present eating habits.
  • Describe the food or beverage consumed. For example: milk – whole, 2%, nonfat; toast – whole-wheat, white, buttered; chicken – fried, baked, breaded.
  • Record the amount of each food consumed using standard measurements as much as possible, such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
  • Include any added items. For example: tea with 1 teaspoon sugar, potato with 2 teaspoons butter, etc
  • Please record all beverages, including water. List them in the “Beverage” category.
  • Please record all bowel movements and their consistency (regular, loose, firm, etc.).

Diet Diary