New Patient Intake Form

Date

Referred by

Name

Date of birth

Age

Height

Weight

Occupation

Telephone: Home

Work

Home address:

Email address:

EMERGENCY CONTACT: In case of an emergency, please contact: Name:

Phone #

Relationship

Primary Physician:

Phone #

Chief complaint:

How long have you had this health concern?

What makes your health concern worse? (exercising, certain movements, heat, cold etc.)

What makes your condition better? (rest, heat, ice, etc.)

What other forms of treatment have you sought for this condition, when did you have these treatments, and were they helpful?

Please indicate if you have any significant illnesses:CancerDiabetesHepatitisHerpesHerniaHeart DiseaseHypertensionSeizures/EpilepsyStrokeArteriosclerosisVaricose veinsSleep apneaAsthmaHIVBlood clotting disorderEmotional DisordersInfectious DiseasesTuberculosisOsteoporosisSexually Transmitted Diseases

Other:

Any Drug allergies?YesNo

If Yes, please explain:

Do you follow any diet?

Alcohol IntakeYesNo

How Much?

List any medications and supplements you are currently taking: (Continue on back if necessary.)

Supplements:

The information on this form is correct and accurate to the best of my knowledge