New Patient Intake Form (Page 3 of 4) in pdf

Please check if you experience any of the following on a regular basis:

Head, Eyes, Ears, Nose, Throat

Glasses

Ear Ringing

Teeth Removed

Night Blindness

Hearing Loss

Numerous Cavities

Eye Strain

Earaches

Teeth Grinding

Eye Pain

Ringing in Ears

TMJ

Red Eyes

Headaches

Gum Problems

Itchy Eyes

Migraines

Lip Sores

Spots in Eyes

Concussions

Mouth Sores

Spots in Visions

Throat Drainage

Excessive Saliva

Blurred Vision

Throat Tickle

Facial Pain

Glaucoma

Sore Throat

Facial Numbness

Cataracts

Swollen Glands

Sinus Problem

Nosebleeds

Lump in Throat

Sinus Drainage

Heaviness of Head

Enlarged Thyroid

Respiratory

Difficulty Breathing

Tight Chest

Pleurisy

Shortness of Breath

Asthma

Phlegm/Congestion

Chronic Cough

Wheezing

Rattling Sound with Breath

Acute Cough

Pneumonia

Can’t Sleep Lying Down

Cardiovascular

Hypertension (High Blood

Blood Clots

Hypotension (Low Blood

Pressure)

Chest Pain

Rapid Heart Rate

Fainting

Palpitations

Edema (Swelling)

Irregular Heart Rate

Slow Heart Rate

Pacemaker

Gastrointestinal

Nausea

Diarrhea

Dark Colored Stool

Vomiting

Constipation

Light Colored Stool

Acid Regurgitation/Reflux

Use Laxatives

Mucus in Stools

Gas/Flatulence

Use Antacids

Blood in Stools

Hemorrhoids

Hiccups

Use Fiber

Rectal Pain/Itching

Bloating

Use Digestive Enzymes

Fissures

Bad Breath

Intestinal Pain

Bowel Movement 1X/Day

Vomiting Blood

Poor Appetite

Bowel Movement Greater

Bowel Movement Less than

than 1X/Day

1X/Day

Genito-Urinary

Pain with Urination

Bed Wetting

Impotence

Frequent Urination

Wake to Urinate

Premature Ejaculation

Urgent Urination

Frequent UTIs

Nocturnal Emissions

Incomplete Urination

STD

Blood in Urine

Increased Libido

Decreased Libido

Dribbling

Kidney Stones

New Patient Intake Form Page 3

Related Articles

Related forms

Related Categories