Patient Intake Form

Medical History
Please complete before our consultation. If there are questions that you would prefer not to answer or you do not know the answer then just leave them blank.
Name
First NameLast Name
Date of Birth
DayMonthYear
Occupation
How did you hear about me?
Contact Information
Address:
Street Address
Street Address Line 2
CityCounty/State/Province
Postal / Zip CodeCountry
Email
example@example.com
Can we contact you over email?
Preferred Phone Number

	Mother	Father	Brother	Sisters	Maternal Grandparent	Paternal Grandparent
Allergies	1	2	3	4	5	6
Asthma	7	8	9	10	11	12
Arthritis	13	14	15	16	17	18
Cancer	19	20	21	22	23	24
Diabetes	25	26	27	28	29	30
Heart Disease	31	32	33	34	35	36
High Blood Pressure	37	38	39	40	41	42
Liver Disease	43	44	45	46	47	48
Kidney Disease	49	50	51	52	53	54
Anxiety	55	56	57	58	59	60
Depression	61	62	63	64	65	66
Other Mental Health Issues	67	68	69	70	71	72
Addiction or Alcoholism	73	74	75	76	77	78

Health Assessment and Medical Information
Current Height
Current Weight
Has your weight ever fluctuated by more than 10lbs in a short period of time?
YesNoI have struggled with my weight now for years
Details, if applicable
Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..
YesNo
Type a question
Are you taking any supplements, minerals/vitamins, herbs or other natural health care products?
YesNo
List here
Any known allergies?

Please quickly rate your level of satisfaction with the following areas of your life.

(1 star = not satisfied, 5 star = very satisfied)
Health
Any Comments?
Diet
Any Comments?
Occupation
Any comments
Fitness Level/Physical Activity
Any Comments?
Living/Home Environment
Any Comments?
Family and Friends
Any Comments?
Romantic Partnership/Significant Other
Any Comments?
Is there anything else you would like to add that you feel is important and has not been covered?
Today's Date
DayMonthYear
Thanks for taking the time to complete this intake form.
Should be Empty:

Medical History