New Patient Intake Form (Page 2 of 4) in pdf

New Patient Intake Form Page 2

Current Symptoms (Please check if any of the following apply)

Headaches

Urination Difficulties

Constipation/Diarrhea

Vision Problems

Infertility

Skin Disorders

Jaw/Teeth Pain

Impotence

PMS

Ear Pain

Muscular Pain

Menstrual Disorders

Sinus Pain/Problems

Joint Dysfunction/Pain

Menopausal Problems

Throat Pain/Problems

High/Low Blood Pressure

Anxiety

Breathing Difficulties

Depression

Chest Pain

Chills

Overly Emotional

Excess Thirst

Fever

Fatigue

Lack of Thirst

Indigestion

Dizziness

Spontaneous Sweating

Insomnia

Weight Loss

Night Sweating

Nervousness

Weight Gain

Lack of Sweating

Other:___________________________________________________________________________

**Please indicate any areas of pain on the diagram below**

Any additional information about yourself -

_____________________________________________________________________________________

Typical Daily Diet and Exercise

______________________________________________________________________________

New Patient Intake Form Page 2