Medical Intake Form

DelCare Health Solutions, LLC

Please complete all of the following as accurately as possible:

Name:

Age

Birthdate

Sex

Address

City

ZIP

Home Phone:

Work Phone:

Occupation

Full Time Part Time

Employer

Education Level

Married Separated Divorced Widow Single Other

Children (ages)

How did you hear about us?

Are you familiar with Homeopathy?

Please list your most concerning health care problems at this time (in order of importance to you):

Add Health Care Problems:

When did your chief problem or illness begin?

What do you think may have caused your chief complaint?

PAST MEDICAL HISTORY

Past Surgical History:

Please list any Surgical Procedures you have had and the approximate dates:

Add new row

Past Medical History:

Indicate illness not listed:

Family History:

Please check any of the following diseases tend to run in your family and list what relative (father, grandmother, etc.)

Diabetes:

Heart Disease:

Stroke:

High Blood Pressure:

Seizures:

Cancer:

Asthma:

Allergies:

Eczema:

Blood disorder:

Social History:

Please check any of the following you have used in the past or currently:

Alcohol (beer, wine or spirits)

Illegal Drugs

Birth Control Pills

Vitamins / Supplements

Tobacco (cigarettes, cigar, pipe)

Tobacco (chewing)

Coffee

Herbal Products

Medications:

List all of the Prescription Medicines or Over the Counter Drugs you are now taking:

Allergies:

Please list any medications to which you are allergic:

Please list any foods that you are allergic or sensitive:

Female:

Age menstruation began:

How frequent are periods: every

How long do Periods usually last?

days Number of Pregnancies

Number of Births

Miscarriages

Abortions

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