New Patient Intake- Elevate Human Potential
Name (Last, First, Middle)
Date of Birth (month/date/year)
Prefer not to say
Not Hispanic or Latino
Hispanic or Latino
Black or African American
Native American or other Pacific Islander
Straight or heterosexual
Lesbian, gay, or homosexual
Something else, please describe.
Choose not to disclose
Emergency Contact Name
Emergency Contact Phone
How did you hear about us?
Personal Medical History- Please mark all that apply
Alzheimer's Disease/ Dementia
Blood pressure problems
Chronic Fatigue Syndome
Carpel Tunnel syndrome
Eyes, ears, nose, throat problems
Gastroesophageal reflux (GERD)
Inflammatory Bowel Disease, Irritable Bowel Syndrome (IBS)
Kidney or Bladder disease
Liver or Gallbladder disease (stones)
Neurological problems (Parkinson's, Huntington's, paralysis)
Thyroid Trouble/ Hormone imbalance
Sexually Transmitted Diseases (STDs)
Seasonal affective disorder
Urinary Tract Infections
Men- Benign prostatic hyperplasia (BPH)
Men- Prostate Cancer
Men and Women- Decreased Sex Drive
Men and Women- Breast Cancer
Men and Women- Infertility
Women- Menstrual irregularities
Women- Cystic breasts
Women- Fibroids/ovarian cysts
Women- Premenstrual syndrome (PMS)
Women- Pelvic Inflammatory Disease
Women- vaginal infections
Women- Surgical menopause
Personal Medical History- Please elaborate on any of the conditions you mentioned above
Family History- Please mark all that apply going all the way through to your grandparents- we will discuss further in clinic
Eating Disorder/ Obesity
Neurological disorders (Parkinson's, Huntington's, paralysis)
List any current medication or supplements you are taking
Health Habits- check all that apply
Regularly use Caffeine (daily)
Occasionally use Caffeine (1 time a week)
Rarely/Never use Caffeine (1-2 times a month or less)
Regularly use Tobacco or Tobacco products (daily)
Occasionally use Tobacco or Tobacco products (1 time a week)
Rarely/never use Tobacco or Tobacco products (1-2 times a month or less)
Regularly use alcohol (daily)
Occasionally use alcohol (1 time a week)
Rarely/never use alcohol (1-2 times a month or less)
Regularly exercise (4-7 times per week)
Occasionally exercise (2-3 times per week)
Rarely/never exercise (1-2 time a month or less)
Nutrition- please list typical meals throughout your entire day. What do you normally eat and in what amounts. Do you follow any specific diet?
Reason for your office visit: Please write down the issue(s) you have been dealing with and the timelines for those issue(s) you are seeing Dr. Karla for.
What are your goals for your treatment? Please mark all that apply
Get out of pain
Return to all my activities of daily living
Get back to performing
Keep my body functioning well all year around
Please tell me your specific pain/movement goals for your treatment. What are you looking to get out of your treatment(s) at Elevate Human Potential?
What types of care have you done in the past for the issue(s) you are coming in for today?
On a scale of 1-10 what is your current level of pain?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service