New Patient Intake Form Page 4

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Musculo-Skeletal
Muscle Weakness
Chronic Pain
Limited Range of Motion
Muscle Cramps
Acute Pain (short-term pain)
Arthritis
Muscle Spasms
Injuries
General Aches
Joint Pain
Muscle Atrophy
Joint Instability
Falls
Neurological
Fainting/Syncope
Dizziness
Vertigo
Drowsiness
Loss of Balance
Poor Memory
Tremor
Convulsions
Paralysis
Stroke/CVA/TIA
Seizures
Numbness
Neurophysiological
Depression
Worry Easily – Anxious
Abuse Survivor
Irritable
Unresolved Grief
Receiving Counseling
Easily Stressed
Frightened Easily
Received Counseling
Easily Frustrated
Numbness
Poor Memory
Skin and Hair
Rashes
Psoriasis
Hair Loss
Hives
Acne
Hair Changes
Ulcerations
Itching
Hair Breaking
Eczema
Dandruff
Thin Slow Growing Nails
Fungal Infection
Premature Graying
Skin Changes
Vitality and Immune System
Frequent Colds
Chronic Mental Cloudiness
Slow Wound Healing
Frequent Flu
Low Energy
Tender/Achy All Over
Less Ability to Adapt
Lethargic
Gynecology
N/A
Pregnant
Decreased Libido
Hysterectomy
Could be Pregnant
Increased Libido
Excess Vaginal Discharge
Pregnancies #______
PMS
Vaginal Odor
Miscarries #_______
Pain Before Menstruation
Vaginal Sores
Abortions #_______
Pain During Menstruation
Vaginal Dryness
Pre-Mature Births #___
Pain After Menstruation
Vaginal Itching
Use Birth Control Pills
Bone Density Changes
Vaginal Pain
Use Birth Control, Other
Fibrocystic Breasts
Spotting Between Cycles
Use No Contraceptives
Breast Lumps
Blood Clots
Use HRT
Breast Tenderness
Heavy Bleeding – Weeks
Menopausal
Mastectomy
Regular Self Breast Exams
Peri-Menopausal
Lumpectomy
Age of first period __________
Age of Menopause_________
Date of Last PAP ___________________
Date of Last Mammogram ____________
Current Menses:
Date of last period __________ Days between periods _______ Days of Bleeding ______
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