PATIENT INTAKE FORM

Date:                            Social Security #:                                      E-mail address:                                          
Name:                                                                                                                                                          
Age:                Gender:  M / F    Wt:                      Height:                      Date of Birth:                                   
Street:                                                                                                                                                          
City:                                                                                             State:                       Zip:                           Telephone: home (       )                             work: (        )                            Do you have Medicare?   Yes / No
How did you find out about our office?   ____________________________________________________
Person to notify in case of emergency:                                                                                                          
Relationship:                                                Their Phone number:                                                                 
Prior or Primary Physician:                                                                   MD, DO, DC, ND, LAc, other (circle)
Address:                                                                                                                                                      
Phone #:                                                                           Fax #:                                                                  
If you want us to communicate with this doctor, please circle “YES” and initial here: ________      Yes / No
Reason for Visit:

Other Issues:
 

Please list all current medications                                             Please list all medical diagnoses
and supplements with their dosages:                                              and any past surgeries with dates:

                                                                                                                                     Please list all allergies:
Do you smoke cigarettes?  YES / NO   packs per day:            
Do you drink alcohol?       YES / NO   drinks per week:         
Do you drink caffeine?      YES / NO   doses per day:            
What other therapies are you using?                                                               
                                                                                                                    
What is your work?                                                                                                                     
With whom do you live?                                                                                
Illnesses in parents or siblings?