Patient Intake Form

All information is confidential and kept private.

Do you presently, or have you had in the recent past, any of the following?

(Please check all appropriate boxes.)

Headaches

Temperature / Sweating

Skin

Sleep

Respiration / Chest

Appetite / Digestion / Urination

Women Only

Name & Personal Information

Email

Do you presently, or have you had in the recent past, any of the following?

(Please check all appropriate boxes.)

Do you presently, or have you had in the recent past, any of the following?

(Please check all appropriate boxes.)

Headache Location

Headache Quality

Eyes, Ears, Nose, Throat

On the average, how frequently do you move your bowels?

Fill out before your appointment

Fill out before your appointment

Also fill out the contact form to reserve a date and time for appointment

Men

Psycho-Emotional

Musculoskeletal

Please rate your overall general level of pain.  (1=mild, 10=severe)

Diet & Lifestyle

(Please check all appropriate boxes)

Approximate number of times per week you have? (Place an amount near the food)

Please rate your overall general level of energy.  (1=lowest, 10=optimal)

Do you presently, or have you had in the recent past, any of following?   (Please check all appropriate boxes.)

Do you presently, or have you had in the recent past, any of following?   (Please check all appropriate boxes.)

Do you presently, or have you had in the recent past, any of the following?   (Please check all appropriate boxes.)

Please check all that apply:

Phone:

Miscellaneous

Do you presently, or have you had in the recent past, any of the following?

(Please check all appropriate boxes.)

Do you presently, or have you had in the recent past, any of the following?

(Please check all appropriate boxes.)

Do you presently, or have you had in the recent past, any of the following?

(Please check all appropriate boxes.):

Do you presently, or have you had in the recent past, any of the following?

(Please check all appropriate boxes.)

Do you presently, or have you had in the recent past, any of the following?