bioFIT Medicine Intake Form
New Patient
Name: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Address, City, St, ZIP: *
Your answer
Contact Phone: *
Your answer
Email Address: *
Your answer
Drivers License number: *
Your answer
Current Primary Care Physician *
Your answer
How did you hear about us? *
Your answer
Preferred Pharmacy & location: *
Your answer
What health concerns and symptoms bring you to our office today? *
Your answer
What would you most like to achieve with this health consultation? *
Your answer
When was the last time you felt great? Why? *
Your answer
Personality Profile: Select the letter that best fits your personality *
Personality Profile: Select the letter that best fits your personality *
Personality Profile: Select the letter that best fits your personality *
Personality Profile: Select the letter that best fits your personality *
Past Medical History: check all that apply currently or in the past
PAST
PRESENT
Anxiety
Anemia
Asthma
Seasonal allergies
Year round allergies
Artificial joints or implants
Back pain or sciatica
Blood clotting problems
Bleeding disorder
Cancer
Chronic fatigue syndrome
Carpal tunnel sydrome
Constipation
Chronic pain
Chronic indigestion
Chrohn's/ulcerative colitis
Chest pain
Chronic Bronchitis
COPD/Emphysema
Depression
Diabetes
Eczema
Fribomyalgia
Gall stones
Gout
Heart disease
Heart failure
Heart attack/Angina
Herniated disc
Head injury/Concussion
Hepatitis/Liver disease
High blood pressure
High cholesterol
HIV/AIDS
Intestinal disease
Insomnia
Irregular heart beat
Kidney disease
Kidney stones
Lyme disease
Mononucleosis
Migraines
Menstrual disorders
Neck pain
Osteoarthritis
Psoriasis
Psychiatric illness
Pneumonia
Rheumatoid arthritis
Recurrent sinus infection
Reproductive problems
Sexual/libido problems
Seizure disorder
Stomach ulcers
Skin problems/dermatitis
Shoulder pain
Stroke
TIA
Sleep apnea
Thyroid disease
Tendonitis
Explain any above
Your answer
Birth History: check all that is known *
Required
Childhood History: Did you have any health issues as a child? *
Your answer
Dental History: Do you have any amalgam fillings? *
Dental History: Have you ever had fillings replaced? *
Dental History: Have you had any cavities in the last 2 years? *
Dental History: Do you grind your teeth? *
Dental History: List any materials used in fillings and how many you have had:
Your answer
Do your gums ever bleed? *
Required
Past Surgical History: (check all that apply) *
Required
Explain any checked answers above in detail
Your answer
Current medication/supplements taking (include brand and year started) *
Your answer
Antibiotic Exposure: Childhood *
Required
Antibiotic Exposure: Adulthood *
Required
Medication Allergies and reactions (i.e. pennicillin=hives) *
Your answer
Known food/environmental allergies and any food or skin allergy tests performed?
Your answer
Social History: Check all that apply *
Required
Social History: Number of Marriages *
Required
Social History: Employed outside the home? *
Required
Social History: Do you travel for work? If so, how often? What type of work? *
Your answer
Social History: Do you have children? (check all that apply) *
Required
Tobacco & Drug Use: (check all that apply) *
Required
Tobacco & drug use: Explain type/frequency/and duration for any above checked boxes
Your answer
Alcohol: Check all that apply *
Required
Alcohol: I do not drink because
Stress: check all that apply *
Required
Stress: Explain any checked boxes above *
Your answer
Life Satisfaction Score: rate 1-4 (1 is poor, 4 is great) *
1 (not great)
2 (ok)
3 (good)
4 (great)
n/a
Job
Social life
Close Friends
Sex
Attitude
Self Love
Children
Parents
Spouse/Significant other
Financial
Sleep: check all that apply *
Required
Sleep: explain any above checked boxes
Your answer
Exercise Habits: typical each week *
Required
Exercise Habits: explain any above checked boxes *
Your answer
Exercise Types: (check all that apply) *
Required
Family History: *
Alive
Deceased
N/A
Mother
Father
Brother(s)
Sister(s)
Family History: explain any above deaths, age at death and the health issues with each *
Your answer
Family History: check all that apply in your extended family *
Required
Family History: Does anything unusual run in your family?
Your answer
Family History: Any psychiatric illness in your family (please explain) *
Your answer
Preventative Test History: Check any that you have had done *
Required
Preventative Test History: include month/year of test and the test result
Your answer
Current Weight *
Your answer
Desired Weight: *
Your answer
Age of last desired weight: *
Your answer
Highest Adult Weight & Age *
Your answer
Lowest Adult Weight & Age *
Your answer
How many times have you dieted before?
Your answer
What diets have worked?
Your answer
Neuro-Gastro-Immunology: (check all that apply)
Explain any above checked boxes and types of food triggers:
Your answer
Typical Meal: Breakfast (include time of day) *
Your answer
Typical Meal: Snacks (include times of day you snack and how often) *
Your answer
Typical Meal: Lunch (include time of day) *
Your answer
Typical Meal: Dinner (include time of day) *
Your answer
Typical Meal: Before bedtime (include time of day) *
Your answer
DIGESTIVE TRACT: last 48 hours *
0 = never or almost never have symptom
1 = occasionally have it, effect is not severe
2 = occasionally have it, effect is severe
3 = frequently have it, effect is not severe
4 = frequently have it, effect is severe
Nausea or vomiting
Diarrhea
Constipation
Bloating feeling
Belching or flatulence
Heart burn
Intestinal/stomach pain
EARS: last 48 hours. *
0 = never or almost never have symptom
1 = occasionally have it, effect is not severe
2 = occasionally have it, effect is severe
3 = frequently have it, effect is not severe
4 = frequently have it, effect is severe
Itchy ears