CLIENT INTAKE FORMDate: ______/______/______

Legal Name: ___________________________________________________Date of Birth: _______/_______/______ Age: _______ Preferred Name: ____________________ Preferred Pronoun __________ Occupation______________________________________ Address: ___________________________________________ City_______________________ State_________ Zip______________Email ________________________________________ Phone: _________________________________ Ok to leave messages? Y/NHow did you hear about our clinic? Emergency Contact: ____________________________________________ __________________________________________ Phone: __________________________Relationship: ___________________Y/N Do you have a Primary Care Provider? Name: ___________________________________ Phone: _____________________Y/N Do you have any infectious diseases? If yes, please list: ________________________________________________________

Please explain your current or most relevant health concerns:1)_______________________________________________________________________________________________2)_______________________________________________________________________________________________3)_______________________________________________________________________________________________________

Please list any Major Illness, Injury, Surgery or Accident you have experienced. Include dates. X-Rays / CAT Scans / MRIs / NMRs ?____________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ___________________________________________

Y/N Do you have any medical conditions that have been diagnosed by a physician? Please describe: __________________________________________________________

Please list any medications, vitamins, and/or supplements you are currently taking: list reasons.__________________________________ __________________________________ __________________________________

1

__________________________________ __________________________________ ____________________________________________________________________ __________________________________ __________________________________

Y/N Do you have any food sensitivities or allergies? If yes, please list: __________________________________________________

Y/N Do you have any ailments that are restricting you from performing daily tasks? If yes, what do you have trouble accomplishing?

List any significant Family Health History that may impact your health: (cancer, stroke, etc)

Please indicate on the diagrams below any areas where you are currently experiencing Discomfort (D), Pain (P), Numbness (N), or Tingling (T):

CIRCLE conditions you are experiencing NOW / UNDERLINE all you have experienced in the PAST

Neck / Shoulder Pain Arm Pain Leg Pain Muscle Spasms / Cramps Joint Pain TendonitisBack Pain: Upper / Mid / Low Head Injuries Osteoporosis Broken/Fractured bones ______________

Where in your body do you hold stress? ______________________________

Have you ever received any of the following healthcare treatments? (circle all that apply):

2

Acupuncture Shiatsu Massage Chiropractic Osteopathic Naturopathic Physical Therapy Other _________________________For what reason(s)?

LIFESTYLE:Living Situation (circle): single with roommates/family with spouse with children/how many? ______ ages _________________

Describe your typical diet: ______________________________________________________________________________________Y/N Do you regularly drink Water? How many cups / day ? ________ Y/N Do you consume Caffeine? Type & Amount _______________________ Y/N Do/Did you use Tobacco? If yes, How often? ______________________________/When did you Quit?________________Y/N Do you use Alcohol or Recreational Drugs? Type & Frequency?__________________________________________________Y/N Do you sleep well during the night? How many hours per night do you sleep? ______ Y/N Do you wake feeling rested? Y/N Do you have difficulty falling or staying Asleep? Y/N Do you Exercise? Activities/How often? __________________________________________________________________

What do you do to relax?______________________________________________________________________________________

Signed: _____________________________________ Date: ___________________________HEALTH HISTORY: CIRCLE Current conditions / UNDERLINE Past conditions

EYES/EARS/NOSE/THROATImpaired VisionEye Pain / StrainGlasses / ContactsTearing / DrynessGlaucomaHeadachesHead InjuryHearing ProblemsEar RingingEaraches

Sinus ProblemsAllergies/Hay FeverNose BleedsLoss of SmellFrequent Sore ThroatsTMD / Jaw Problems

RESPIRATORYPneumoniaFrequent Common ColdsDifficulty BreathingShortness of Breath

Persistent CoughAsthmaEmphysemaPleurisyTuberculosisENERGY/IMMUNITYFatigueSlow Wound HealingChronic InfectionsChronic Fatigue Syndrome EMOTIONALMood Swings

3

Nervousness / IrritabilityAnxiety / DepressionOther: __________________NEUROLOGICNumbness / TinglingParalysisVertigo / DizzinessSeizures / Epilepsy

CARDIOVASCULARHigh/Low Blood PressureChest PainSwelling of AnklesPalpitations/FlutteringHeart AttackStrokeIrregular HeartbeatHigh CholesterolCongestive Heart Failure Varicose VeinsBlood Clots

GASTROINTESTINALChanges in AppetiteNausea/Vomiting Heartburn / Acid RefluxMouth soresUlcersBelching / Passing GasAbdominal Pain Gall Bladder Disease / StoneLiver DiseaseHepatitis

HemorrhoidsConstipation / DiarrheaBlack/Clay Color StoolBloody StoolsENDOCRINEDiabetes (Type HypoglycemiaHypothyroidHyperthyroidNight SweatsFeeling Hot / ColdOTHERCancer (Type) ________________ Autoimmune Disease (Type) _________________________Bruising Easily Cold Hands / Feet AnemiaWeight gain / LossSleep Disorders ______________

GENITO-URINARY TRACTKidney DiseaseKidney StonesPainful UrinationFrequent UTIFrequent Urination Urinary IncontinenceImpaired UrinationBlood in Urine

MALE REPRODUCTIVE:Sexual DifficultiesProstrate Problems

Testicular Pain / Swelling Penile DischargeOther ____________________________FEMALE REPRODUCTIVEDo you have any reason to believe you may be pregnant? Y / N If so, how far along? ______________________Irregular CyclesHeavy FlowPainful PeriodsClottingVaginal DischargePremenstrual ProblemsBleeding Between CyclesMenopausal SymptomsDifficulty ConceivingBreast Lumps / TendernessNipple DischargeMenstrual & Birthing History:Age of First Menses:_______ Date of Last Period________Period Length: _______# Days Between Periods:_____Birth Control Type:____________# of Pregnancies: ________# of Live Births: ________# of Miscarriages: ________# of Abortions: ________

Initial ____________Date:________

4

5