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Intake Form

Confidential Patient Health Record

PERSONAL HISTORY

MF
MarriedSingleWidowedDivorcedSeparated
SpouseWorkers' Comp.Auto InsuranceMedicareMedicaidN/A
Personal Health Insurance (Name)
Health Card #

CURRENT HEALTH CONDITION

YesNo
JobAuto AccidentHome InjuryFallOther
YesNo
Nerve PillsPain Killers/Muscle RelaxersBlood Pressure MedicineInsulinOtherN/A
YesNo

PAST HEALTH HISTORY

AppendectomyTonsillectomyGall BladderHerniaBack SurgeryBroken BonesOtherN/A
NoneDoctor's Name & Approximate Date of Last Visit

Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.

CHECK ANY OF THE FOLLOWING ILLNESSES YOU HAVE HAD:
  • PneumoniaMumpsInfluenzaRheumatic FeverSmall PoxPleurisyPolioChicken PoxArthritisTuberculosisDiabetesEpilepsyWhooping CoughCancerMental DisordersAnemiaHeart DiseaseLumbagoMeaslesThyroidEczema
  • intake CoffeeTeaAlcoholCigarettesWhite Sugar
YesNo
CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD IN THE PAST 6 MONTHS:
  • MUSCULO-SKELETAL CODE Low Back PainPain Between ShouldersNeck PainArm PainJoint Pain/StiffnessWalking ProblemsDifficult Chewing/Clicking JawGeneral Stiffness
  • GENITO-URINARY CODE Bladder TroublePainful/Excessive UrinationDiscolored Urine
  • NERVOUS SYSTEM CODE NervousNumbnessParalysisDizzinessForgetfulnessConfusion/DepressionFaintingConvulsionsCold/Tingling ExtremitiesStress
  • C-V-R CODE Chest PainShort BreathBlood Pressure ProblemsIrregular HeartbeatHeart ProblemsLung Problems/CongestionVaricose VeinsAnkle SwellingStroke
  • GENERAL CODE FatigueAllergiesLoss of SleepEar AchesHearing Difficulty
  • EENT CODE Vision ProblemsDental ProblemSore ThroatFeverHeadachesStuffed Nose
  • MALE/FEMALE CODE Menstrual IrregularityMenstrual CrampsVaginal Pain/InfectionBreast Pain/LumpsProstate/Sexual DysfunctionOther ProblemsLiver ProblemsWeight Trouble
FEMALES ONLY:
YesNoNot Sure
FAMILY HISTORY

The following members have the same or similar problem as I do:

  • MotherFatherBrotherSisterSpouseChild
  • GASTRO-INTESTINAL CODE Poor/Excessive AppetiteExcessive ThirstFrequent NauseaVomitingDiarrheaConstipationHemorrhoidsLiver ProblemsGall Bladder ProblemWeight TroubleAbdominal CrampsGas/Bloating After MealsHeartburnBlack/Bloody StooColitis
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