New Patient Intake Form (Page 2 of 3) in pdf

Please check the box if you experience or have experienced any of the following conditions:

□ Allergies

□ Asthma

□ Addiction

□ Kidney disease

□ Arthritis

□ Osteoporosis

□ Lung disease

□ HIV/AIDS

□ Pneumonia or bronchitis

□ High/low blood pressure

□ Skin problems

□ Anemia

□ Prostatitis

□ Cancer

□ Mental illness

□ Heart disease

□ Thyroid disease

□ Neurological conditions

□ Addiction

□ Fibromyalgia

□ Seizures

□ Liver disease

□ High cholesterol

□ Diabetes

□ Stroke

□ Gallbladder disease

□ Sexually Transmitted Inf.

□ IBS/chrones/colitis

Please check the box if you have experienced any of the following symptoms in the past MONTH:

□ pain/weakness of

□ muscle pain or

□ insomnia

□ abdominal pain

□ shortness of breath

lower back

tension

□ pain/weakness of

□ tremors or poor

□ heart palpitations

□ bloating

□ difficulty breathing

knees

motor control

□ frequent urination

□ muscle cramps

□ dream disturbed

□ gastrointestinal

□ cough

sleep

colic or gas

□ incontinence

□ numbness or

□ anxiety

□ diarrhea

□ pain with breathing

tingling

□ night sweats

□ dizziness

□ restless sleep

□ constipation

□ spontaneous

sweating

□ low libido

□ headache

□ panic attacks

□ foul smelling stools □ lack of sweating

□ impotence

□ vision changes

□ lack of joy

□ excessive appetite

□ frequent cold or flu

□ infertility

□ dry, red or watery

□ poor appetite

□ skin problems

eyes

□ edema

□ irregular menstrual

□ joint pain or

□ grief

periods

swelling

□ painful or burning

□ painful menstrual

□ nausea

urination

periods

□ ringing in ears

□ PMS

□ acid reflux

□ excessive fear

□ mood swings

□ fatigue

□ irritability or

□ muscle weakness

excessive anger

□ memory loss

□ over thinking

□ excessive worry

What do you do to support your well-being?

What is your main goal of treatment?

New Patient Intake Form Page 2

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