Intake Form

Heartfelt Wellness Intake Form

Name:*
Birthdate*
Marital Status:*
Age:*
Weight;*
Address:
Phone (Day):*
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Phone (Cell):*
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E-mail:*

Please list all the members of your household:

1. Name, Age:
2. Name, Age:
3. Name, Age:
4. Name, Age:
Occupation:*
Employer:
Employer Address:
MAIN PROBLEM:
1. What is the Chief Complaint (main problem) you are coming in for today?:*
2. When did this problem begin? What happened in your life around that time? What do you think caused it?:*
3. What aggravates the problem (certain types of food or weather, movement, light, noise, touch, heat/cold, or anything else you can think of? Also, what makes the problem better?:
4. At what time of the day or night is the problem the worst and when is it better? Specify an hour if you can:
5. What symptoms can you identify that accompany the problem, if any?:
6. Please describe your temperament: For ex: are you moody, angry, jealous, irritable, shy, stubborn, lack of self-esteem, etc.? Make a bullet list of at least ten traits:
7. What was your nature/ personality like as a child?:
8. In what way is your nature/ personality still the same today?:
9. What foods do you desire? (Even if they are not healthful choices):
10. What foods do not agree with you (for ex: I avoid milk b/c it gives me gas)?:
11. Are you a warm or chilly person?:
12. What temp do you prefer your drinks? Ice Cold, Hot or Room Temp?
13. Are you a thirsty person or thirst less?:
14. Do you perspire? Where? Does it stain your clothes?:
15. How is your sleep?:
16. What is your energy level from 0-10?:
17. What kinds of movies will you NOT watch?:
18. What are your hobbies?:
WOMEN:
Number of Pregnancies:
Number of Children:
Number of Miscarriages:
Number of Abortions:
2. At what did menses age (period) begin? Or if you have gone through menopause, at what age?:
3. How frequently does (or did) your periods come?:
4. What about the duration, abundance, color, time of day when flow is greatest, any odor or clots?:

MEN:

1. Do you have any prostate problems?
2. Do you have any difficulty in obtaining or maintaining an erection?
3. Do you experience premature ejaculation?:
4. How often are you able to achieve orgasm? Always, Often, Sometimes, Rarely, Never
5. Does intercourse aggravate or ameliorate your condition? Please explain:

FOR CHILDREN: (Complete only if the patient is a child)

Mother's pregnancy:
1. Did you have any difficulty falling pregnant?:
2. Describe any problems you had during pregnancy?:
3. Describe your emotional state during pregnancy, including any stresses that you had?:
4. Check all that apply to describe your labor?:
5. Describe any complications during labor?:
6. How long were you in labor?
7. What did you use for pain relief during labor?:
8. Is bedwetting a problem for your child?:
9. Is masturbating an issue for your child?:
10. What best describes your child's growth and development? Take into account age learning to walk, talk, etc.

HEALTH HISTORY:

1. Frequency of bowel movements (BM): If you don’t have a BM, do you use laxative? Bloating? Gas?
2. How frequently do you get colds and flus?:
3. Have you had any childhood illnesses twice, or in a very severe form or after puberty?:
4. Have you had vaccinations since the standard childhood ones? Have you ever had an adverse reaction or unusual reaction to vaccinations?:
5. Have you had any surgeries? What type and when?:
6. What other medical problems/diagnoses have you been treated for?:
7. Describe any discharges other than your periods. (Color, smell, abundance, texture and time of day you get them the most.):
8. Have you had any chronic urinary infections or problems?:
9. Have you had syphilis, gonorrhea, genital warts, herpes or any other sexually transmitted disease?:

SEXUALITY:

1. Is your sexual desire above or below normal?
2. How do you feel about sex in general?:
3. Do you consider yourself a sexual person?:
4. How important is sex in a/your relationship?:
5. Do you feel sexually satisfied?:
FAMILY HISTORY
1. List any mental diseases, physical diseases and the causes/ages of death of parents, siblings and grandparents on both sides:
Parents: (if living list ages & illnesses or if passed on please list age at death and cause of death?)
Mother:
Father:
Brothers and Sisters: (if living list ages & illnesses or if passed on please list age at death and cause of death)
Brothers:
Sisters:
Grandparents: (if living list ages& illnesses or if passed on please list age at death and cause of death?)
Maternal Grandmother:
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:
Current Vitamins, Herbs, Supplements? Please list.
Medications:

DIET:

Foods you ate yesterday:

Breakfast:
Lunch:
Dinner:

Typical foods eaten:

Breakfast, Lunch, Dinner, Snacks:
Select the following items which apply to you & indicate amount used:
Coffee:
Candy:
Tea:
Cigarettes:
Alcohol:
Artificial Sweetener:
Recreational Drugs:
Herbs:
Exposure to Toxic Chemicals:
Please list nutritional goals:
SYMPTOM SURVEY:
Place an “N” beside any item that applies to a current issue and a “P” for anything you had in the PAST.
Migraines:
Change in Bowel Habits:
Vomiting:
Headaches:
Diarrhea, persistent:
Painful Swallowing:
Dizziness:
Constipation, frequent:
Varicose Veins:
Loss of Consciousness:
Laxative Use:
Heartburn:
Convulsions:
Hemorrhoids:
Abdominal Pains:
Blurred Vision:
Vomiting Blood:
Pace Maker:
Double Vision:
Rectal Bleeding:
Artificial Organs/Parts:
Eye Pain:
Black Bowel Movements:
False Teeth:
Hearing Loss:
Yellow Jaundice:
Motion Sickness:
Ringing of Ears:
Tooth Abscess:
Vertigo:
Crooked Teeth:
Gum Disease/ Bleeding:
Muscle Weakness
Gall Stones:
Muscle Atrophy:
Nose Bleeds
Hay Fever or Allergies:
Back Pain:
Sciatica:
Crooked Spine:
Anemia
Leg Weakness/ Numbness:
Acne:
Cysts:
Insomnia:
Tranquilizer Use:
Depression:
Breast Lumps:
Shortness of Breath:
Nausea:
Palpitations, Heart Racing:
Prostate Issues:
Easy Bruising: