Adult Intake Form

Note:
Please do not enter information using ALL CAPITAL LETTERS. Intake form submissions that contain text in ALL CAPITAL LETTERS will not be processed. Form fields marked with an asterisk (*) require an entry.

GENERAL INFORMATION

* Name

* Date of birth (M/D/Y)
Year:

* Today's date

ADDRESS

* Street Number & Name:

* Apartment Code:

* City:

* Province:

* Postal Code:

* Sex: Male Female

E-mail:

Telephone Number(s):

* Home:	Work:

How did you hear about us?

*WHAT ARE YOUR HEALTH CONCERNS IN ORDER OF IMPORTANCE?

*PLEASE LIST ALL CURRENT MEDICATIONS
(prescription, over-the-counter, vitamins, herbs, homeopathics, etc.)

*YOU PAST MEDICAL HISTORY

Allergies/Hayfever

Asthma

Alcoholism/Drug Abuse

Cancer

Depression

Heart Attack

High Blood Pressure

High Cholesterol

Ostheoporosis

Hepatitis

Thyroid Disease

Cold Sores

Anemia

Frequent Antibiotic Use

Other

IMMUNIZATIONS YOU HAD?

DPT (diphtheria, pertussis, tetanus)

Haemophilus, influenza B

Hepatitis A

Hepatitus B

Tetanus booster; when?

Flu Shott

MMR (measles, mumps, rubella)

Polio

Smallpox

OTHER

Please indicate any serious conditions, illnesses or injuries, and any hospitalizations along with approximate dates?

*Do you have any allergies (medicines, environmental, food etc.)?
Yes No

*FAMILY HISTORY

Includes parents, grandparents, brothers, sisters

Allergies
Asthma
Alcoholism/Drug Abuse
HeartAttack/Stroke/Angina
High blood pressure
Cancer
Diabetes
Depression
Hepatitis
Thyroid Disease
Arthritis
Kidney disease
Glaucoma
Osteoporosis
Other

*LIFESTYLE INFORMATION

*Do you regularly exercise? Yes No

* What do you do for exercise? How much? How often?

Tobacco – type and amount per day?

Caffeine – type and amount per day (includes coffee, tea, pop)?

How much alcohol do you drink per day/week (please specify)?

Recreational drugs – type and frequency of use?

How many glasses of water do you drink per day?

Do you miss meals? If yes, which one? Breakfast Lunch Dinner No I don't miss meals

Describe your typical daily diet:

Breakfast

Lunch

Dinner

Snacks

Beverages

*ENVIRONMENT

Are you exposed to significant tobacco smoke (work, home, etc.)? Yes No

How would you describe the emotional climate of your home?

How stressful is your work or other aspects of your life?

How well do you handle these stresses?

*CLARIFYING YOUR GOALS

For your care to be successful to you, what do you see happening over the next 3 months?

How much do you think each of the following affects you personally? Please check box.

Family & Friends Very much Somewhat Very little

Love & Romance Very much Somewhat Very little

Career & Power Very much Somewhat Very little

Health & Fitness Very much Somewhat Very little

Money & Financial Very much Somewhat Very little

Environment & Earth Connection Very much Somewhat Very little

Personal Growth & Spirituality Very much Somewhat Very little

Fun & Recreation Very much Somewhat Very little

How motivated are you to invest the time, money and energy necessary to improve your health?

GENERAL

Poor Appetite

Fever

Sweat easily

Localized weakness

Weight Gain

Always feel hot

Strong thirst (cold or hot drinks)

Poor Sleep

Night Sweats

Tremors

Bleed or Bruise Easily

Peculiar tastes/smells

Always Feel Cold

Sudden Energy Drop

Fatigue

Chills

Cravings

Poor Balance

Weight Loss

Always Feel Cold

Sudden Energy Drop

SKIN AND HAIR

Rashes

Ithching

Dandruff

Changes in hair or skin texture

Hives

Eczema

Recent Moles/Growth

Warts

Ulcerations

Pimples

Loss of hair

Other

HEAD, EYES, EARS, NOSE & THROAT

Dizzines

Glasses/Poor Vision

Watery or dry/itchy eyes

Earaches

Hearing Loss

Reccurent sore throats

Hay Fever

Nose Bleeds

Headaches