Intake & Health History Form

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Source of Referral

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor's Name

Doctor's Phone

Doctor's Address

Past Treatment (from other practitioners)

Improve Lifestyle

Pain Relief

Stress Relief

Support in Healing/Recovery

Rehabilitation

Health Advice for Healing

Improve Well Being

Improve Symptoms

Other

Urinary Stream Changes

Painful Urination

Difficulty Maintaining Erection

Nocturnal Urination

Difficulty Obtaining Erection

Family History of Prostate Disease

Painful Ejaculation

Family History of Prostate Cancer

History of Back Injury

History of STD

PSA Test Results

Difficulty Experiencing Orgasm

Sperm Count Results

Hobbies

Smoking

Interests

Caffeine

Exercise

Sports

Mobility/Walking Aids

Flexibility

Range of Motion

Drinking

Clear

High

Even

Agitated

Flat

Chaotic

Low

Fatigue

Dull

Vibrant

Lyme Disease

Strep

Epstein Barr

Pneumonia

Morning Stiffness

Ear Ringing

Grinding

Ear Stuffiness

Jaw Pain

Ear Pressure

Clicking

Ear Blockage

Locking

Difficulty Opening Jaw

Difficulty Chewing

Clenching

How long do you sleep on average?

Do you struggle with insomnia?

Does your energy fluctuate?

Is your energy constant?

When is your energy highest?

When is your energy lowest?

What is your energy level upon awakening?

Substance Use Disorder

Alzheimer Disease

Anxiety Disorder

Mood Disorder

Schizophrenia

Stress

Pes Planus (Flat Feet)

Pes Cavus (High Arch)

Onychauxis

Hallux Valgus

Bunions

Onychoptosis (Nail Loss)

Overlapping Toes

Onychomycosis (Nail Fungus)

Corns/Callouses

Involuted Nails (Curved/Pinched)

Itchy or Peeling Skin

Thickened Nails

Dry/Cracked Skin

Yellow Nails

Heel Fissures

Onychocryptosis (Ingrown Nail)

Previous Amputations

Severe Menstrual Pain

PMS

Menopause

Hysterectomy

First Period

Last Period

Number of Pregnancies

Number of Live Births

Last PAP test

Abnormal PAP test

Irregular Periods

Menstrual Cycle Length

Menstrual Period Length

Menstrual Cramping

Heavy Bleeding

Endometriosis

Infertility

Unwanted hair growth

Premenstrual Syndrome

Breast Cancer

Ovarian Cancer

Osteoporosis

Current Menopausal Concerns

Currently Pregnant

Birth Control Method

Implants

Fibroids

PCOS

Uterine Polyps

Spotting

Dark Blood

Clots

Brown Spotting

Pencil Like Stool

Heaviness in Pelvis

Urinary Incontinence

Pelvic Organ Prolapse

Pelvic Floor Injury

Scar Tissue

Pelvic Pain

Pain with Sex

Cancer Type

Date of Diagnosis

Location

Status

Treatment: Surgery

Date of Surgery

Lymph Nodes Removed

Side Effects of Surgery

Reconstruction Date

Treatment: Chemotherapy

Number of Chemo Treatments

Side Effects of Chemo

Treatment: Radiation

Number of Radiation Treatments

Area of Radiation

Nodes Irradiated

Side Effects of Radiation

Other Treatments

Medical Devices

Nausea

Vomiting

Mouth Sores

Weight Loss

Weight Gain

Bone Pain

Adhesions

Incision

Pressure Sensitivity

Pain

Former Injuries

Loss of Movement

Abnormal Skin Sensation

Memory Problems

Edema

Low Platelet

Low White Count

Blood Clot

Excessively Warm/Cold

Lymphedema

Heart Condition

Lung Condition

Dry Skin

Fragile Skin

Radiation Skin Reaction

Hair Loss

Fatigue

Systemic Infection

Infectious Condition

Current Tumour

Enlarged Lymph Nodes

Enlarged Spleen

Enlarged Liver

Radioactivity

Neck

Left Side of Neck

Right Side of Neck

Upper Back

Left Side of Upper Back

Right Side of Upper Back

Mid Back

Left Side of Mid Back

Right Side of Mid Back

Low Back

Left Side of Low Back

Right Side of Low Back

Chest

Abdomen

Left Arm

Right Arm

Left Shoulder

Right Shoulder

Left Elbow

Right Elbow

Left Wrist

Right Wrist

Left Hand

Right Hand

Left Leg

Left Thigh

Left Calf

Right Leg

Right Thigh

Right Calf

Left Gluteal

Right Gluteal

Left Hip

Right Hip

Left Groin

Right Groin

Left Knee

Right Knee

Left Ankle

Right Ankle

Left Foot

Right Foot

Sacrum

Tailbone (coccyx)

Bulimia Nervosa

Schizophrenia

Anorexia Nervosa

Antisocial Personality Disorder

Claustrophobia

Sleep Disorder

ADD

Depression

Social Anxiety Disorder

ADHD

Generalized Anxiety Disorder

Autism

Obsessive Compulsive Disorder

Asperger Syndrome

Obsessive Compulsive Personality Disorder

Bipolar Disorder

Panic Disorder

Acute Stress Disorder

Borderline Personality Disorder

PTSD

Agoraphobia

Cluster

Migraines

Rebound

Headaches

Sinus

Chronic Daily Headache

Tension

Other Headaches

Osgood-Schlatter Disease

Dupuytren's Contracture

Jaw Pain (TMJD)

Muscular Dystrophy

Joint Stiffness / Swelling

Chronic Myofascial Pain Syndrome

Osteomalacia

Myasthenia Gravis

Spasms / Cramps

Chronic Fatigue Syndrome

Ankylosing Spondylitis

Paget Disease

Osteoporosis

Whiplash

Bone Disease

Psoriatic Arthritis

Torticollis

Temporomandibular Joint Dysfunction

Tendonitis/Bursitis

Osteoarthritis

Compartment Syndrome

Gout

Scleroderma

Baker's Cyst

Sinus Problems

Spondylolisthesis

Dislocation

Fracture

Scoliosis

Recti Diastasis

Artificial Joints / Special Equipment

Hereditary/Congenital Deformity

Strain/Sprain

Broken Bone / Fracture

Degenerative Disk Disease

Ehlers-Danlos Syndrome

Joint Injury

Arthritis

Plantar Fasciitis

Amyotrophic Lateral Sclerosis (ALS)

Bone or Joint Disease

Fibromyalgia

Carpal Tunnel Syndrome

Other Musculoskeletal

Diverticulitis

Acid Reflux

Digestive Conditions

Ulcerative Colitis

Eating Disorder

Hiatal Hernia

Esophageal Disorder

Stomach Disorders

Gastroparesis

Crohn's Disease

Fecal Impaction

Intestinal Gas/Bloating

Intestinal Polyps

Adaptive Aids

Celiac Disease

Irritable Bowel Syndrome

Constipation

Poor Appetite

Diarrhea

Abdominal Hernia

Stomach Disorder

Other Gastrointestinal

HIV/AIDS

Hepatitis

Blood Thinner Medication

Hypercoagulability

Haemophilia

HIV

Stroke

Polycythemia

Fainting Spells

Thrombosis/Embolism

High Cholesterol

Anemia

Bleeding Disorder

Other Blood

Athletes Foot

Rosacea

Chemical Burn

Athlete's Foot

UV Burn

Moles

Hypersensitive Reactions

Herpes

Hypersensitive Reaction

Cosmetic Surgery

Eczema

Melanoma/Carcinoma

Severe Irritability

Bruise Easily

Pigmentary Disorder

Non-Surgical Scars

Plantar's Wart

Surgical Scars

Melanoma

Acne

Infectious Skin Conditions

Psoriasis

Skin Conditions

Allergic Dermatosis

Rash

Skin Irritations

Allergic to Iodine

Combination Skin

Dry Skin

Oily Skin

Mature Skin

Sun Damage

Using ALPHA Hydroxy Acids

Using RETIN A

Other Skin

Hyperlipidemia

Varicose Veins

Blood Pressure

Heart Attack

Cardiovascular Conditions

Aneurysm

Angina

Pericarditis

Postural Orthostatic Tachycardia Syndrome

Phlebitis

Atherosclerosis

Raynaud Disease

Blood Clots

Cardiac Arrhythmia

Rheumatic Heart Disease

Lymphedema

Cardiovascular Accident

Chest Pain

Chronic Ischemic Heart Disease

Valve Disorders

Pacemaker

Heart Condition

Stroke

Chronic Venous Insufficiency

High Blood Pressure

Cold Hands

Heart Disease

Fainting Spells

Congenital Heart Defect

Low Blood Pressure

Cold Feet

Coronary Artery Disease

Myocardial infarction

Swelling

Congestive Heart Failure

Acute Coronary Syndrome

Other Cardiovascular

Dural Ectasia

Herniated Disc

Seizure Disorder

Burning

Post Polio Syndrome

Cerebral-vascular Accident

Sciatic Pain

Multiple Sclerosis

Transient Ischemic Attacks (TIA)

Tingling

Vertebral and Spinal Cord Injury

Fibromyalgia

Bell's Palsy

Stroke

Stabbing

Loss of Sensation

Huntington Disease

Shingles / Herpes

Peripheral Neuropathy

Chiari Malformation

Brain Disorder

Twitching of Face

Epilepsy

Syringomyelia

Chronic Pain Disorder

Fatigue

Tethered Cord

Shingles

Cerebral Palsy

Brain Injury

Sleeping Disorders

Cerebrospinal Fluid Leak

Dizziness

Parkinsons

Cerebral Vascular Accident (Stroke)

Carpal Tunnel

Numbness

Other Neurological

Chronic Cough

Sinus Problem

Shortness of Breath

Respiratory Conditions

Asthma

Tuberculosis

Respiratory Tract Infection

Emphysema

COPD

Bronchitis

Cystic Fibrosis

Infectious Respiratory Conditions

Other Respiratory

Motion Sickness

Tinnitus

Vertigo

Ear Problems

Hearing Loss

Conductive Hearing Loss

Meniere Disease

Other Hearing

Urinary Tract Infection

Bladder Disorder

Chronic Kidney Disease

Congenital Kidney Disease

Electrolyte Imbalance

Kidney Stones

Renal Cysts

Urinary Incontinence

Other Kidney

Pelvic Inflammatory Disease

Premenstrual Syndrome

Uterine Disorder

Breast Disorder

Pregnancy

Ectopic Pregnancy

Gynaecological Conditions

Endometriosis

Menopause

Prostatitis

Menstrual Cycle Disorder

Enlarged Prostate

Ovarian Cysts/Tumors

Other Reproductive

Diabetes

Arthritis

Cardiovascular

Respiratory

Cancer

Acute Pancreatitis

Hyperthyroidism

Temiskaming Diabetes Program

Hypothyroidism

Diabetes

Blood Sugar Managed?

Adrenal Fatigue

Pituitary and Growth Disorder

Wound Healing Status?

Prostate Condition

Other Endocrine

Hodgkin Lymphoma

Allergies

Rheumatoid Arthritis

Infectious Mononucleosis

Anaphylaxis

Lupus

HIV/Aids

Sjogren's Syndrome

Leukemia

Cancer

Non-Hodgkin Lymphoma

Other Immune

Upper Respiratory Infection

Vision Problems

Dentures

Weakened Immune Function

Vision Loss

ADHD

Mental Health Issues

Autism

Liver Disease

Surgical Pins or Wire

Dental Implants

Insomnia

Dental Bridge

Music Preference

Hearing Impaired

Contact Lens

Loss of Balance

Other Medical Conditions

Other Diagnosed Diseases

Breakfast

Lunch

Dinner

Snacks

Prenatal (check boxes to enter details below)

Due Date

Trimester

Weeks Pregnant

Number of previous pregnancies/births?

Anemia

Leaking Amniotic Fluid

Bladder Infection

Blood Clot (Phlebitis)

Abdominal Cramping

Diabetes

Edema/Swelling

Leg Cramps

Miscarriage

Nausea

Problems with Placenta

Preterm Labour

Pre-eclampsia (toxemia)

Sciatica

Separation of Rectus Muscle (diastasis recti)

Separation of Symphysis Pubis

Twins or More

Visual Disturbances

Previous C-Section

Heart Attack

Stroke

Carpal Tunnel Syndrome

Allergy to Nut Oils

Hypoglycemia

High Risk Pregnancy

Birth Location

Doula

Placental Location

Baby's Sex

Sacral Injury

Tailbone Injury

Injury Rehabilitation

Positive Reinforcement

Address Health Issues

Strength Training

Alternative Therapy

Stress Relief

Balance

Flexibility

Improve Fitness

Increase Well-Being

Massage Frequency

Other

Date of Injury

Which State?

MVA Claim

Workers Comp Claim

Crime Victim Comp.

Which best describes what you are experiencing

Pain

Mild

Getting Worse

Ache

Moderate

Staying the Same

Tension

Disabling

Getting Better

Discomfort

Constant

Imbalance

Intermittent

Increases with Activity

Decreases with Activity

No Change

Other

Food

Environmental

Medical

Latex

MCAD

Mastocytosis

Physical Abuse History

Negative Self-Talk

Anger

Mental Abuse History

Other Emotions

Anxiety

PTSD

Confusion

Fear

Stress Response and Coping Strategies

Sadness

Overall mood and energy level

Depression

Rate the stress in your life (1-10)

Grief

Despair

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