For New Patients: Name * First Name Last Name Date of Birth * MM DD YYYY Sex: * Male Female Non-binary Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Weight Height Employer Occupation Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Do you plan to use insurance? Yes, I know that I have benefits Can you check my coverage? No Physician and Physician Contact Information Is it okay to contact your physician? Yes No Ask me later What are your health goals and concerns? * Do you have a pacemaker or any implants? Yes No Check all that apply to your TEMPERATURE: Cold hands/feet Sweaty hands/feet Hot overall Cold overall Afternoon flush Night sweats Hot flashes Thirst Check all that apply to your RESPIRATION: Nasal discharge Nose bleed Sinus congestion Cough Dry mouth/throat/nose Sore throat Difficulty breathing Snoring Check any that apply to your EYES: Dry Bloodshot Itchy Hot Water Gritty Visual disturbances Check all that apply to you: Frequent cavities Easily broken bones Weak/sore knees Cold sensation in knees Low back pain Memory problems Check any that apply to your DIGESTIVE FUNCTIONS: Large appetite Bad breath Bleeding/swollen/painful gums Heartburn/Acid reflux Belching Hiccups Stomach pain Vomiting Ulcers Bitter taste in mouth Check all of the following that apply to your ELIMINATION: Wake frequently to urinate Discolored or bloody Scanty Profuse Cloudy Strong odor Difficult Dribbling Check all that apply to your BODY: General sensation of heaviness Brain fog/mental sluggishness Swollen hands/feet/joints Chest congestion Nausea Chest congetion Headache Numbness/Tingling Muscle spasms/twitching/cramping Neck/shoulder tension Seizures/convulsions Skin rashes Other pain Check any that apply to your HEART and SLEEP: Palpitations Chest Pain Chest pain traveling to shoulders Difficulty falling asleep Difficulty staying alseep Vivid/sleep disturbing dreams Waking unrested Check any that apply to your EMOTIONAL STATE: Stress Anxiety Irritability Frustration Unable to adapt to stress Sadness/Grief Worry/overthinking Fear Easily startled Check any that apply to your ORGANS: Lumps Impotence Nocturnal emissions Pain/itching of genitalia Menopause Irregular period PMS Abnormal scans/pap smear Fibroids STDs Number of Live births Number of miscarriages Number of abortions I have completed this form truthfully and to the best of my ability * Yes No Thank you for filling out the intake form! Almost done…Please continue to Step 2: Consent Form
