New Patient Intake FormThis intake form is collapsible for easy viewing. Hit the plus sign [+] next to the heading to open and close the form sections.Please make sure all required fields are filled out or form will not submit upon clicking the submit button. May be easiest to fill out on a computer Personal Information plus 3 minus3 Name * Name First Name First Name Last Name Last Name Email * Occupation Date of Birth * Home Phone Work Phone Mobile Phone * Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Height Weight Source of Referral Emergency Contact plus 3 minus3 Name Name First Name First Name First Name First Name Relationship to Client Phone Doctor plus 3 minus3 Doctor's Name Doctor's Phone Number Doctor's Address Doctor's Address Doctor's Address Doctor's Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Other Information plus 3 minus3 Reason for Today's Visit (Primary Concern): * When did you first notice this problem? What, if anything, makes it better? What makes it worse? Medical Evaluation? Secondary Concerns: Have you been treated for any of the above with conventional medicine, herbs, acupuncture or any other modality? * Yes No If yes, Please describe: Are you currently under a Physician's care? * Yes No If yes, Please describe: Do you have an infectious disease? * Yes No If yes, Please describe: Additional Notes: Nancy's Notes Medications/Supplements plus 3 minus3 Are you currently taking any prescription drugs? * Yes No If yes, Please describe: *Drug Name & Dosage followed by the Purpose/Condition List any Side Effects: Are you currently taking any supplements and/or vitamins? * Yes No If yes, Please describe: *Supplement/Vitamin Name & Amount followed by the Purpose/Condition List any Side Effects: Allergies plus 3 minus3 Do you have Allergies? * Yes NoIf yes, please check which: Foods Medications Bites/Stings Seasonal Animals OtherOther Please describe reaction(s): Additional Notes: Nancy's Notes Family Medical History plus 3 minus3 Please check if any of the following applies to any family members: * AIDS Asthma Seizures Alcoholism Diabetes, Type I or II Stroke Allergies Heart Disease Mental Illness High Blood Pressure Cancer OtherOtherPlease Describe the Following: Mother's Health * Father's Health * Living Deceased Living Deceased Siblings? * Grandparents * Living Deceased Paternal - Both Deceased Maternal - Both Deceased Paternal - Both Living Maternal - Both Living Paternal - One Living & One Deceased Maternal - One Living & One Deceased Additional Notes: Nancy's Notes Personal Health History plus 3 minus3 Please check if any of the following apply: * AIDS Alcoholism Asthma Allergies Arteriosclerosis Birth Trauma (yours) Diabetes Emphysema Epilepsy Endocrine Disorder Gout Heart Disease Hepatitis High Blood Pressure Multiple Sclerosis Thyroid Disease Childhood Fevers Childhood Illnesses OtherOther Additional Notes: Nancy's Notes Surgeries & Injuries plus 3 minus3 Please List all Major Surgeries with Approx. Dates: Please list any Significant Trauma/Injuries with approx. date of injury (auto accidents, falls, etc.) Additional Notes: Nancy's Notes Current Symptoms plus 3 minus3 Please check if any of the following apply: * Headaches Vision Problems Jaw/Teeth Pain Ear Pain Sinus Pain/Problems Throat Pain/Problems Breathing Difficulties Chills Fever Indigestion Insomnia Nervousness Urination Difficulties Infertility Impotence Muscular Pain Joint Dysfunction/Pain High/Low Blood Pressure Depression Overly Emotional Fatigue Dizziness Weight Loss Weight Gain Constipation/Diarrhea Skin Disorders PMS Menstrual Disorders Menopausal Problem Anxiety Chest Pain Excess Thirst Lack of Thirst Spontaneous Sweating Night Sweating Lack of Sweating OtherOther **Please indicate any additional areas of pain below: Additional Notes: Nancy's Notes Lifestyle plus 3 minus3 Write out any scars, tattoos, or piercings (even if you got them years ago). If you had spinal anesthesia or spinal taps, please make note of that as well in italic font. Scars: Birthmarks: Tattoos: Piercings: Spinal anesthesia/Spinal taps: Areas of Pain:If you have no scars, tattoos, or piercings, check the NONE button NONEWhich is your dominant hand? Left RightPlease check if any of the following apply: Live Alone Live with Spouse/Significant Other Live with Roomate(s) Live with Parents Live with Children Enjoy your Work Enjoy your Home Enjoy your Social Life Work 9-5 Work 2nd Shift Work 3rd Shift Work Inconsistent Hours Manage Own Business Unemployed Student Full-Time Student Part-Time Have Family Support Have Financial Support Enjoy Hobby Religious Spiritual Connection Exercise Seldom Exercise Occasion Exercise Often OtherOther Additional Notes: Nancy's Notes Diet & Personal Habits plus 3 minus3 Please check if any of the following apply: Currently Use Tobacco - smoking # packs per day?# packs per day? Currently Use Tobacco - chewing how often per day?how often per day? Currently Use Tobacco - vaping how often per day?how often per day? Currently Use Alcohol # drinks per week?# drinks per week? Former Tobacco - Smoking Year Quit?Year Quit? Former Tobacco - Chewing Year quit?Year quit? Cocaine Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? Heroin Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? Methamphetamines Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? THC - Smoking Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? THC - Vaping Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? THC - Edible Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? Other Street DrugsOther Street Drugs Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? CBD Past or Present? How Often? Approx. Date Started or Stopped?Past or Present? How Often? Approx. Date Started or Stopped? Drink Caffeine # cups per day?# cups per day? Drink Coffee # cups per day?# cups per day? Caffeinated tea # cups per day?# cups per day? Diet Drinks # cups per day?# cups per day? Tried any other diets? (paleo, keto, intermittent fasting, weight watchers etc) Please list them herePlease list them here Nutrasweet # per day?# per day? Splenda # per day?# per day? Saccharine # per day?# per day? Use Fluoride toothpaste Currently use Recreational Drugs Exercise Regularly Vegetarian Vegan Healthy Diet Eat MSG Eat Transfats; partially hydrogenated fats Eat a lot of Fried Foods Eat a lot of Dairy Eat a lot of Sweets Eat a lot of Red Meat Eat Soy Normal weight for Height Underweight Overweight Any additional information about yourself (Please write here): Additional Notes: Nancy's NotesUpload Medical Tests plus 3 minus3 If you have any recent medical tests (Blood Results, Ultrasound imaging, CT scan, MRI imaging, etc.) that could help Nancy understand more about your condition and what might be out of balance, please upload them here.You can also bring a physical copy in to be scanned for your records as well.Please note: All files uploaded are protected and secure. File Upload Drop a file here or click to upload Choose FileMaximum file size: 12.58MB Complete Medical History plus 3 minus3 Head, Eyes, Ears, Nose, Throat Glasses Night Blindness Eye Strain Eye Pain Red Eyes Itchy Eyes Spots in Eyes Spots in Vision Blurred Vision Glaucoma Cataracts Nosebleeds Heaviness of Head Ear Ringing Hearing Loss Earaches Ringing in Ears Headaches Migraines Concussions Throat Drainage Throat Tickle Sore Throat Swollen Glands Lump in Throat Enlarged Thyroid Teeth Removed Numerous Cavities Teeth Grinding TMJ Gum Problems Lip Sores Mouth Sores Excessive Saliva Facial Pain Facial Numbness Sinus Problem Sinus Drainage OtherOther Additional Notes: Nancy's NotesDental Do you have any Mercury Amalgam Fillings? YES NO Tooth numbers for all Mercury Amalgam Fillings (separated by comma): Do you have any Root Canals? YES NO Tooth numbers for all Root Canals (separated by comma): Do you have any Crowns? YES NO Tooth numbers for all Crowns (separated by comma): Do you have any Extractions? YES NO Tooth numbers for all Extracted teeth (separated by comma): Additional Notes: Nancy's NotesRespiratory Difficulty Breathing Shortness of Breath Chronic Cough Acute Cough Tight Chest Asthma Wheezing Pneumonia Pleurisy Phlegm/Congestion Rattling Sound with Breath Can't Sleep Lying Down Additional Notes: Nancy's NotesCardiovascular Hypertension (High Blood Pressure) Hypotension (Low Blood Pressure) Chest Pain Palpitations Slow Heart Rate Irregular Heart Rate Rapid Heart Rate Edema (Swelling) Pacemaker Fainting Blood Clots Additional Notes: Nancy's NotesGastrointestinal Nausea Vomiting Acid Regurgitation/Reflux Gas/Flatulence Hemorrhoids Rectal Pain/Itching Fissures Bowel Movement 1x/Day Bowel Movement Greater than 1x/Day Bowel Movement Less than 1x/Day Diarrhea or Loose Stools Constipation Use Laxatives Use Antacids Hiccups Bloating Bad Breath Vomiting Blood Dark Colored Stool Light Colored Stool Mucus in Stool Blood in Stool Use Fiber Use Digestive Enzymes Intestinal Pain Poor Appetite OtherOther Additional Notes: Nancy's NotesGenito-Urinary Pain with Urination Frequent Urination Urgent Urination Incomplete Urination Kidney Stones Bed Wetting Wake to Urinate Frequent UTIs Sexually Transmitted Disease Blood in Urine Dribbling OtherOther Additional Notes: Nancy's NotesMusculo-Skeletal Muscle Weakness Muscle Cramps Muscle Spasms Joint Pain Joint Instability Chronic Pain (long-term pain) Acute Pain (short-term pain) Injuries Muscle Atrophy Falls Limited Range of Motion Arthritis General Aches OtherOther Additional Notes: Nancy's NotesNeurological Fainting/Syncope Drowsiness Tremor Stroke/CVA/TIA Dizziness Loss of Balance Convulsions Seizures Vertigo Poor Memory Paralysis Numbness Additional Notes: Nancy's NotesNeurophysiological Depression Irritable Easily Stressed Easily Frustrated Worry Easy - Anxious Unresolved Grief Frightened Easily Numbness Abuse Survivor Receiving Counseling Received Counseling Poor Memory Additional Notes: Nancy's NotesSkin & Hair Rashes Hives Ulcerations Eczema Fungal Infection Psoriasis Acne Itching Dandruff Premature Graying Hair Loss Hair Changes Hair Breaking Thin, Slow-Growing Nails Skin Changes Additional Notes: Nancy's NotesVitality and Immune System Frequent Colds Frequent Flu Less Ability to Adapt Chronic Mental Cloudiness Low Energy Lethargic Slow Wound Healing Tender/Achy All Over Additional Notes: Nancy's Notes For Women plus 3 minus3 Age of 1st period (Menarche): Age of last period (Menopause): Length of Cycle (# Days per Month) Duration of Flow (# Days of Bleeding) Color of Flow Do you Experience Any Clots? Yes No Average number of pads used on 1st day Average number of pads used on 2nd day Average number of pads used on 3rd day Average number of pads used on 4th day Average number of pads used on 5th day Average number of pads used on 6th day Location of Pain (Please indicate before, during, or after menses): Lower Abdomen Lower Back Thighs OtherOtherNature of Pain (Please indicate before, during, or after menses): Cramping Burning Dull Consistent Stabbing Aching Bloating Intermittent Bearing Down Sensation Are you pregnant? Yes NoCould you be Pregnant? Yes No # of Pregnancies: # of Live Births: # of Pre-Mature Births: # of Abortions: # of Miscarriages: Additional Notes: Nancy's Notes Date of Last PAP Smear: Date of Last Mammogram: Results: Bone Density Scan: Have you been diagnosed with: Fibroids Fibrocystic Breasts Endometriosis Ovarian Cysts PID OtherOtherOther Conditions/Symptoms: Excess Vaginal Discharge Use Birth Control Pills Use Birth Control, Other Use No Contraceptives Use Hormone Replacement Therapy Mastectomy Lumpectomy Hysterectomy Regular Self Breast Exam Vaginal Dryness Headache Nausea Constipation Diarrhea Swollen Breasts Mood Swings Ravenous Appetite Poor Appetite Hot Flashes Night Sweats Increased Libido Decreased Libido Insomnia Menopausal Peri-Menopausal PMS Breast Lumps Breast Tenderness Vaginal Odor Vaginal Sores Vaginal Itching Vaginal Pain Pain Before Menstruation Pain After Menstruation Spotting Between Cycles Heavy Bleeding - Weeks OtherOther Additional Notes: Nancy's Notes For Men plus 3 minus3 Date of last prostate check-up: PSA Results Lab Results Frequency of Urination? Daytime Nighttime How Often Color of Urine: Clear Murky OtherOther Odor? Other Conditions/Symptoms: Prostate Problems Delayed Stream Dribbling Incontinence Retention of Urine Rectal Dysfunction Increased Libido Decreased Libido Premature Ejaculation Nocturnal Emissions Back Pain Impotence Groin Pain Testicular Pain OtherOther Additional Notes: Nancy's Notes Sleep Patterns plus 3 minus3 Usual Bedtime: Usual Wake Time: How Long to Fall Asleep? Do You Experience Wakefulness During the Night? I find that I: Can't go to sleep until after 11PM Go to sleep but awaken at: 11PM - 1AM Go to sleep but awaken at: 1AM - 3AM Go to sleep but awaken at: 3AM - 5AM Go to sleep but awaken at: 5am - 7amI have a problem with fatigue & it is worse during: 5AM - 7AM 7AM - 9AM 9AM - 11AM 11AM - 1PM 1PM - 3PM 3PM - 5PM 5PM - 7PM 7PM - 9PM Any Other Information About Sleep Habits: Additional Information: Nancy's NotesUpon Submitting this form, you will be sent an email prompting you to sign our Informed Consent form. Please make sure to fill that out immediately. Thank you! * I Understand and Agree to fill Informed Consent out immediately upon receiving emailCLICK HERE TO SUBMIT FORM If you are human, leave this field blank.
