bioFIT Medicine Intake Form
New Patient
Email address *
Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Address, City, St, ZIP: *
Contact Phone: *
Email Address: *
Drivers License number: *
Current Primary Care Physician *
How did you hear about us? *
Preferred Pharmacy & location: *
What health concerns and symptoms bring you to our office today? *
What would you most like to achieve with this health consultation? *
When was the last time you felt great? Please explain: *
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
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
Tinnitus
Clear selection
Explain any of the above:
Birth History: check all that is known *
Required
Childhood History: Did you have any health issues as a child? *
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:
Do your gums ever bleed? *
Required
Past Surgical History: (check all that apply) *
Required
Explain any checked answers above in detail
Current medication/supplements taking (include brand and year started) *
Antibiotic Exposure: Childhood *
Required
Antibiotic Exposure: Adulthood *
Required
Medication allergies and type of reactions (i.e. penicillin=hives) *
Known food/environmental allergies and any food or skin allergy tests performed?
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? *
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
Alcohol: Check all that apply *
Required
Alcohol: I do not drink because
Stress: check all that apply *
Required
Stress: Explain any checked boxes above *
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
Exercise Habits: typical each week *
Required
Exercise Habits: explain any above checked boxes *
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 *
Family History: check all that apply in your extended family *
Required
Family History: Does anything unusual run in your family?
Family History: Any psychiatric illness in your family (please explain) *
Preventative Test History: Check any that you have had done *
Required
Preventative Test History: include month/year of test and the test result
Current Weight *
Desired Weight/Bodyfat %: *
Age of last desired weight: *
Highest Adult Weight & Age *