Updated 2021 New Patient Intake Form
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Personal Info
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Gender
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Occupation
Contact Info
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Email
Source of Referral
Address
City
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Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
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Bouvet Island
Brazil
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Chad
Chile
China
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Colombia
Comoros
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Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
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India
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Martinique
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Samoa
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Somalia
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Spain
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Sudan
Suriname
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Swaziland
Sweden
Switzerland
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Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
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Tunisia
Turkey
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Uganda
Ukraine
United Arab Emirates
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Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
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Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
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Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Health Questions
Past Heart Surgery
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Concussion
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Heart Condition
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Congenital Heart Defect
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High / Low blood pressure
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Stroke
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Depression
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HIV/Aids
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Diabetes
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Meniere Disease
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Vertigo
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Asthma
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Epilepsy
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Migraines/Headaches
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Blood thinner medication
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Gastrointestinal
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Mood Disorder
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Cancer
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Pacemaker
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Cardiovascular
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Heart Attack
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Appetite
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Heart Disease
Elevated Blood Cholesterol
Diverticulitis / IBS
Raynaud's Disease
Respiratory Allergies
Weight
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Menstrual Issues
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Racing Heart
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Fertility Issues
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Chronic Pain Condition
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Thyroid Imbalance
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Hepatitis
Food Allergies / Intolerance
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Kidney / Bladder Issues
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Sciatica
Sleep Issues
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Lyme Disease
Anemia
Hypo/Hyperglycemia
Liver / Gallbladder Disease
Numbness
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Constipation
Dizziness / Balance Issues
Gastritis / Pancreatitis
Alcoholism
Chronic Fatigue
Ulcer
Arthritis
Treatment Goals
Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Other
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Lymph Nodes Removed
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Side Effects of Radiation
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Other Treatments
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Allergy
Latex
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Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Coconut Oil
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Sensitive to scents/essential oils
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Environmental
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Food
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Other Allergies
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Emotion / Mood
Anxiety
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Other Emotions
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Confusion
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Overall mood and energy level
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Depression
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Physical Abuse History
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Despair
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PTSD
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Rate the stress in your life (1-10)
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Fear
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Sadness
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Grief
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Stress Response and Coping Strategies
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Mental Abuse History
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Anger
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Negative Self-Talk
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