Initial Consult & Treatment
Confidential Intake Form and Consent
Email *
Todays Date *
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Full Name *
Date of Birth *
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Age today/Gender *
Address: *
Moble number: *
MARITAL/RELATIONSHIP STATUS *
OCCUPATION: *
REFERRED BY: *
HIPPA CLIENT CONFIDENTIALITY AND RELEASE FORM. I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health. Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation. Clients should receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records (Please sign and date below to confirm you have read the above HIPPA CLIENT CONFIDENTIALITY AND RELEASE). *
Primary reason for visit: *
When did your first notice it? *
What brought it on? *
Describe any stressors occurring at the time: *
What activities provide relief? *
What makes it worse? *
Is this condition: *
Required
What kind of Treatments have you had? What Results did you experience? *
SECONDARY COMPLAINT: Significant Illnesses: *
Required
Do you have an Allergies? *
List all Major Operations and Dates: *
List all Accidents / significant Traumas: *
List all Western Diagnosis: *
List all Medicines (taken within the last 6 months including drugs, vitamins and herbs): *
Please review and check the following: *
PAST
PRESENT
N/A
Asthma
Cold Hands or feet
Swollen ankles
Sinus Conditions
Frequent Colds
Seizures
Low Back Pain
Skin Disorders
Sciatica
Painful/Swollen Joints
High Blood Pressure
Low Blood Pressure
Dentures/Partials
Headaches
Sore heels when walking
Anxiety
Depression
Sleep Disturbance
Fainting Spells
Muscular Tension
Varicose Veins
Hemorrhoids
Herniated/Bulging Discs
Artifical/Missing limbs
Contact Lenses
Cancer (past or current)
Numbness in feet or legs when standing
This space is to share more details from above answers if needed:
FAMILY HISTORY: Short answers for the following immediate family members: Please include Mother, Father, Siblings, Maternal Grandparents, Paternal Grandparents.... Any Major Health Issues? Are the Still Living? (If deceased, Cause and Age of Death) *
SYSTEMS REVIEW: *
Dizziness
Numbness
Loss of Balance
None
Other
Neurological
Other Neurological Issues that you would like to share:
SYSTEMS REVIEW: *
Nose Bleeds
Tinnitus
Cataracts
Sinus Problems
None
Other
Head/Sense Organs:
Other Head/Sense Organs Issues that you would like to share:
SYSTEMS REVIEW: *
Difficult Breathing
Coughing
Asthma
None
Other
Respiratory:
Other Respiratory Issues that you would like to share:
SYSTEMS REVIEW: *
Chest pain
Irregular Heart Beat
Bleed-Bruise Easily
None
Other
Cardiovascular:
Other Cardiovascular Issues that you would like to share:
SYSTEMS REVIEW: *
Reflux
Ulceras
Stomach Pain
Hepatitis
None
Other
Gastrointestinal:
Describe your typical Breakfast, Lunch, Dinner, Snacks. *
What is you daily Water Intake? *
What is you daily Caffeine Intake? *
What is the worst item in your diet? *
What foods are your weakness? *
Are you subject to binge eating? *
What foods do you experience bloating/gas/burps after eating? What foods trigger this? *
How often do you have a bowel movement and what is the consistency? *
Do you have any Food Allergies? If so please describe in "other" below. *
Do you use Tobacco? *
Do you use Alcohol? *
Do you use Cannabis? *
If you answered yes or on occasion on question above please share daily/weekly quantity and duration of all that apply.
Have you been under treatment for substance use? *
Other Gastrointestinal Issues that you would like to share:
SYSTEMS REVIEW: *
Kidney Disease
Bladder Infection
Kidney Stones
None
Other
Renal/Urological:
Other Renal/Urological Issues that you would like to share:
SYSTEMS REVIEW: *
Cramps/soreness
Fibromyalgia
Bursitis
None
Other
Musculoskeletal:
Other Musculoskeletal Issues that you would like to share:
SYSTEMS REVIEW: *
Sudden weight change.
Tumors.
Hypo functioning
Hyper functioning
None
Other
Endocrine:
Other Endocrine Issues that you would like to share:
SYSTEMS REVIEW: *
Anemia.
Bleeding Disorders
Enlarged localized swelling
None
Other
Hematological/Lymphatic:
Other Hematological/Lymphatic Issues that you would like to share:
SYSTEMS REVIEW: *
Fungal Infections
Eczema.
Rashes.
Psoriasis
None
Other
Dermatology:
Other Dermatology Issues that you would like to share:
SYSTEMS REVIEW: *
STDs
Infertility.
Infections
Abortion.
Miscarriage.
PP Depression
None
Other
OB/GYN:
Other OB/GYN Issues that you would like to share:
Female Reproductive Health History: Method of Contraception: *
Required
Length of time using your method: *
Last Pap smear and Results: *
Are now or in the past experiencing Fertility Challenges? Yes or No. Please Describe your treatment IVF,etc)... *
Menstrual History (short answers): How old were you at the time of your first menstrual cycle? *
Menstrual History (short answers): What was it like for you to get your first menstrual cycle? *
Menstrual History (short answers): When was your last mensural cycle? *
Menstrual History (short answers): How long does your cycle last? What is the blood like during your menstrual cycle (color and amount) *
Menstrual History (short answers): Are you trying to conceive right now? Is there a possibility that you may be pregnant right now? *
Menstrual History Review and check as indicated: *
PAST
PRESENT
N/A
Heaviness in Pelvis prior to menses
Excessive Bleeding
Dizziness
Water Retention
Endometriosis
Uterine or Cervical Polyps
Vaginal Infection(s)
Bladder Infection(s)
Painful Intercourse
Episodes of Amenorrhea
Dark Thick Blood at beginning of cycle
Dark Thick Blood at end of cycle
Dark Thick Blood at beginning and end of cycle
Headache or Migraine with menses
Bloating
Painful Ovulation
Fibroids
Uterine Infection(s)
Cysts
Urinary Incontinence
Vaginal Dryness
Irregular cycles (inconsistent)
Short Cycles (less than 28 days)
Long Cycles (more than 28 days)
Painful Periods
Rate your interest in Sex: *
Do you have or ever had difficulty experiencing orgasms? *
Have you experienced sexual misconduct or trauma? *
If you answered yes above, Did you undergo counseling for this? *
If you have had sexual misconduct, abuse or trauma and would like to share your story please use this space.
PREGNANCY HISTORY: Number of Pregnancies and Dates *
PREGNANCY HISTORY: Number of Miscarriage(s)and Dates *
PREGNANCY HISTORY: Number of Termination(s) and dates *
PREGNANCY HISTORY: Number of Live Births and dates. *
PREGNANCY HISTORY: Please share and describe if you have had the following: Premature Births? Spotting During Pregnancy? Weak Newborns? Incompetent Cervix? Any other relevant info. *
Describe your experience with Pregnancy. *
Describe your experience with Labor. *
Describe your experience with Birthing. *
Describe your experience with Birthing Postpartum. *
Maternal Family History of (please check all that apply) *
Required
MENOPAUSE: Have you reached menopause? *
Required
MENOPAUSE: If you answered yes above, please answer following questions. 1. What age did you begin mesopause? 2. Did you have any symptoms? 3. Are symptoms getting worse? better? same? 4. Are you on/ or ever been on hormone replacement therapy? (if so, how long? Name and dose? Reason for stopping? 5. Age of Mother at menopause. 6. Any other Concerns/Experience ? *
MENOPAUSE SYMPTOMS: Check the following symptoms that apply to you: *
Required
LIFESTYLE, EMOTIONAL & SPIRITUAL: Answer the following questions from your heart space. There is no wrong or right answer. What is your opinion of yourself? *
Describe the most positive emotion you experience. When and Where do you experience this emotion? *
Describe the most negative emotion you experience. When and Where do you experience this emotion? *
Describe your Spiritual and/or Religious practice. *
What brings you Joy. Makes you feel most alive and happy? *
On a scale of 1 – 10 ( 1 being the lesser, 10 the greater) Please rate yourself in each of these qualities: *