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The document is a patient intake form for Bodyscapes clinic. It collects information about the patient's general health, medical history, lifestyle habits, diet, exercise, sleep, stress levels, and any current health issues or areas of concern. The form asks for details on medications, allergies, family health history, digestion, nutrition, dental health, pain levels, urination, menstruation (for women), libido, and more. The goal is to gather a comprehensive overview of the patient's wellness to help evaluate their needs and develop a treatment plan.
The document is a patient intake form for Bodyscapes clinic. It collects information about the patient's general health, medical history, lifestyle habits, diet, exercise, sleep, stress levels, and any current health issues or areas of concern. The form asks for details on medications, allergies, family health history, digestion, nutrition, dental health, pain levels, urination, menstruation (for women), libido, and more. The goal is to gather a comprehensive overview of the patient's wellness to help evaluate their needs and develop a treatment plan.
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Attribution Non-Commercial (BY-NC)
Format Tersedia
Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
The document is a patient intake form for Bodyscapes clinic. It collects information about the patient's general health, medical history, lifestyle habits, diet, exercise, sleep, stress levels, and any current health issues or areas of concern. The form asks for details on medications, allergies, family health history, digestion, nutrition, dental health, pain levels, urination, menstruation (for women), libido, and more. The goal is to gather a comprehensive overview of the patient's wellness to help evaluate their needs and develop a treatment plan.
Hak Cipta:
Attribution Non-Commercial (BY-NC)
Format Tersedia
Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
General Information _________________________________________
First Name: _________________________________________ _______________________________ _________________________________________ Last Name: ___ _______________________________ List all medications and supplements you Address: are currently taking: _________________________________ _________________________________________ City: _________________________________________ _____________________________________ _________________________________________ State: ___________ Zip code: _________________________________________ ________________ ____ Email: ___________________________________ Any long term or frequent use of Home Phone: antibiotics? _____________________________ _________________________________________ Cell Phone: _ _______________________________ Do you have allergies? _______ Describe: Age: _________ Birth Date: _____ _________________ _________________________________________ Occupation: Digestion/Nutrition ______________________________ How is your appetite? Emergency contact: _____________________ ________________________ Check any issues that apply to you: Phone: □ Constipation □ Loose stools □ ___________________________________ Bloating Primary Physician: □ Gas □ Acid reflux □ Abdominal ________________________ pain Phone: ___________________________________ How many meals per day do you eat? What would you like to be treated for: _______ 1. Are you thirsty? ________________________________________ ___________________________ 2. How much water do you drink per day? ________________________________________ _____ 3. Do you prefer cold or hot beverages? ________________________________________ ________ Do you drink caffeinated beverages? Health History _________ Have any of your blood relatives suffered How many per day? from any of the following (please check): _______________________ □ Diabetes □ High blood pressure □ Do you drink alcohol? Stroke _____________________ □ Cancer □ Heart disease □ Kidney How much? disease ______________________________ List other beverages including juice, rice List major events of your health history milk, almond milk, soy milk, tea, etc. you (illnesses, surgery, accidents, drink; hospitalizations, heavy metal or toxin exposure, etc.): _________________________________________ If not, describe: _________________________________________ ___________________________ __ _________________________________________ What dairy products do you eat? _ ____________ How many hours do you sleep in _________________________________________ general? ___ _ Have lots of dreams? Are you a vegetarian or vegan? ______________________ _____________ Do you feel rested when you wake? List sources of meat/protein: _________ ________________ What is your energy level in general on a _________________________________________ scale of 1-10 (10 being best)? _ _____________________ _________________________________________ _ Exercise/Lifestyle List any food allergies or sensitivities: Do you exercise? _____ How often? _______ __________ _________________________________________ What kind of exercise? _ _____________________ What % of your diet is organic? _________________________________________ _____________ _ Do you have any particular cravings? How long do you exercise for? ________ ______________ Please specify Do you like to exercise? _____________________________ ____________________ Times per week you eat out? Any awareness practices (meditation, ________________ prayer, affirmation, or other practices)? Eat regularly at fast food restaurants? _____________ ________ _________________________________________ Do you eat a lot of processed food? _ __________ Hours of TV you watch daily? Do you eat late at night? ______________ ___________________ Hours spent at the computer daily? Do you chew your food thoroughly? __________ _________ Pain Do you think you get enough fresh fruits, Describe any pain, stiffness, or swelling vegetables, and whole grains daily? in your body: _________ ____________________________________ How would you describe your diet: _________________________________________ □ Unhealthy □ Fair □ Good □ _________________________________________ Fantastic __ How would you rate your cooking skills Do you suffer from migraine or tension on a scale of 1-10 (10 being best)? headache? _______ How often? ________________ _____________ Are you ready and willing to make Do you have any: changes in your diet if need be? □ Dizziness □ Chest pain □ _______________________ Palpitations Sleep □ Floaters in eyes □ Burning, red, itchy Do you sleep soundly? eyes _____________________ Skeletal Any broken bones or fractures? Any problem with ED? _____________ ____________________ How many? _____ Osteoporosis? Difficult urination? ____________ ________________________ Libido good? Teeth _____________________________ Have you had lots of cavities? Other issues: ______________ ______________________________ Any root canals? _____ Gum disease? ________ Urination Ringing in ears? _______ TMJ? Is your urine clear like water?____ cloudy? ______________ ___ Scanty? ____ Yellow? _____ Dark yellow? Emotions (check all that apply to you): ____ □ Anger □ Depression □ Worry □ Do you get up at night to urinate? Anxiety ___________ □ Sad □ Fearful □ Happy □ Other How many times? __________ _________________________ Women’s Health Body Temperature Are your periods regular? Feel cold often? ____ dislike the cold? ____ __________________ Feel hot often? ____ dislike the heat? ____ Check all that apply to you: Have afternoon flushes/fevers? □ Painful periods □ Heavy flow □ ______________ Scanty flow Night or daytime sweats? □ Clotted □ PMS □ Breast tenderness □ __________________ Fibroids □ Hormonal migraine □ Endometriosis Thank you for taking the time to □ Vaginal discharge □ Chronic UTI’s complete this form. If you have any □ Birth control pills □ Other questions regarding filling out this ________________ form, please call Ellie at (847)864- _________________________________________ 6464. If you have more information _ you think I need to know, please use How many pregnancies? the backside to write on. ___________________ Any miscarriages? _______ How many? ______ Are you currently undergoing fertility treatment? ________ Please describe: _________ _________________________________________ _________________________________________ __ Have you started menopause? ______________ Any problematic issues related to menopause? _________________________________________ _________________________________________ __