PHA Medicine Intake FormĀ 
New Patient

Sign in to Google to save your progress. Learn more
Name
*
Date of Birth:
*
MM
/
DD
/
YYYY
Address, City, St, ZIP:
*
Contact Phone:
*
Email:
*
Preferred Method of Contact

*
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
Crohn'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
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?
*
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
Clear selection
Antibiotic Exposure: Adulthood
Clear selection
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
Social History: Employed outside the home?
Clear selection
What is your occupation?

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)
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
Alcohol: I do not drink because (check all that apply)
Stress: check all that apply
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
Clear selection
Sleep: check all that apply
Sleep: explain any above checked boxes

Exercise Habits: typical each week
Exercise Habits: explain any above checked boxes
Exercise Types: (check all that apply)
Family History:
Alive
Deceased
N/A
Mother
Father
Brother(s)
Sister(s)
Clear selection
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
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
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
*
Lowest Adult Weight & Age
How many times have you dieted before?
What diets have worked in the past?

Neuro-Gastro-Immunology: (check all that apply)

Explain any above checked boxes and types of food triggers:
Typical Meal: Breakfast (include time of day)
*
Typical Meal: Snacks (include times of day you snack and how often)
*
Typical Meal: Lunch (include time of day)
*
Typical Meal: Dinner (include time of day)
*
Typical Meal: Before bedtime (include time of day)
*
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
Heartburn
Intestinal/stomach pain
Clear selection
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
Ear aches, ear infections
Drainage from ear(s)
Ringing in ears
Hearing loss
Clear selection
EMOTIONS: 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
Mood swings
Anxiety, fear or nervousness
Anger, irritability, aggression
Depression
Clear selection
ENERGY/ACTIVITY: 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
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
EYES: 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
Watery or itchy
Swollen, red or sticky eyelids
Bags or dark circles
Blurred or tunnel vision
Clear selection
HEAD: 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
Headaches
Faintness
Dizziness
Insomnia
Clear selection
HEART: 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
Irregular heart beat or skipped beat
Rapid or pouding chest
Chest pain
Clear selection
JOINTS/MUSCLE: 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
Pain or aches in joints
Arthritis
Stiffness or limitation
Pain/aches in muscles
Weakness or tiredness
Clear selection
LUNGS: 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
Chest congestion
Asthma
Bronchitis
Shortness of breath