Intake Form: Personal History
Personal History
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First & Last Name *
Date *
MM
/
DD
/
YYYY
Age *
Birthday *
MM
/
DD
/
YYYY
Pronouns *
Address (Street, City, State, Zip) *
Primary Phone *
Work Phone
Cell Phone
Email *
Occupation *
Full-time or Part-time *
Employer
Education *
In your opinion, what are your most important health problems? List as many as you can in order of importance: *
Do you suffer from recurring (Check all that apply): *
Required
Please state (if known) the health of your mother when she was pregnant with you. Did she suffer from (Check all that apply): *
Required
During pregnancy, did your mother take any medications, use recreational drugs/alcohol, etc.? Were there any problems during the pregnancy?  *
Was your own birth (check all that apply): *
Required
Were there any problems with your development as an infant or child? Teething, crawling, talking, etc.? Please list:  *
Did you have any reactions to any vaccinations?  *
Your Health History:
Please select all that apply. 
Now
Past
Addictions
Alcohol
Allergies
Anorexia
Asthma
Bleeding
Bruising
Bilimia
Cancer
Colitis
Depression
Drugs
Thyroid
Diabetes
Epilepsy
Gout
Heart Condition
Hepatitis
Kidney Disease
Liver Diesase
Mental Disease
Migraines
Obesity
Pneumonia
Rheumatism
STD
Tuberculosis
Hospitalizations: List as best you can.
Include Type of Illness/Operation and Date:
Accidents:
Please give details of any serious falls/burns/injuries/etc.
Do You Use:
Please indicate using the drop down boxes and short answer options below if you use the item and the amount you use. 
Coffee *
Amount (If you answered "Yes")
Cigarettes *
Amount (If you answered "Yes")
Alcohol *
Amount (If you answered "Yes")
Painkillers *
Amount (If you answered "Yes")
Other Drugs *
Amount (If you answered "Yes")
Birth Control Pills *
Amount (If you answered "Yes")
Sedatives/ Tranquilizers *
Amount (If you answered "Yes")
Thyroid Medicine *
Amount (If you answered "Yes")
Laxatives *
Amount (If you answered "Yes")
Cortisone *
Amount (If you answered "Yes")
Please list all medications (including herbal, homeopathic, and vitamin/mineral supplements) that you are currently taking. Also a list of all homeopathic remedies and the major orthodox medications you have taken up to date.  *
Immediate Family History: Mother/ Father/ Brothers/ Sisters/ Grandparents etc. 
Please check below if you know (or can find out) if any of the following have occurred in your immediate family: 
 *
Required
Please list if there are any common diseases, mental illnesses, or addictions, or ailments in your family history: *
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