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Adult Intake Form

Date*

Month

Day

Year

First name*

Last name*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Email*

Phone*

Birthday*

Month

Day

Year

Height*

Weight*

Gender*

Occupation

Emergency Contact*

Phone*

Marital Status

Description of what you would like to address:*

What treatments have you tried?

Has anything been successful? If so, what was it?

With whom do you live?

Do you have any pets or farm animals? If so, what kind?

Have you lived or traveled outside the United States? If so, when and where?

Have you or your family experienced any major life changes? If yes, please comment:

Have you experienced any major losses in life? If so, please comment:

How much time have you lost from work or school in the past year due to current problem(s)?

Previous jobs:

On a scale from 1-10, how stressful would you say your days are?

Do you have any artificial joints or implants? If so, which ones

List past medical and surgical history.

How often have you taken antibiotics?

How often have you taken oral steroids?

What medications are you currently taking?

List all vitamins, minerals and other supplements that you are currently taking.

What is your typical daily diet?

Are you on a special diet?

Yes

No

How much of the following do you consume each week?

Tea:

Coffee:

Soda:

Other Caffeine:

Dairy:

Cheese:

Bread:

Sugar:

Candy/Chocolate:

Dessert:

Do you feel worse if you eat certain foods? If so, what are they?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, please list the food(s) and symptom(s).

Have you ever had a food that you craved or really "binged" on over a period of time? If so, what was it?

Do you have an aversion to certain foods? If yes, what foods?

How many bowel movements do you have per day?

Do you have any constipation (straining or less than 1 bowel movement a day) or diarrhea (loose stool)?

Yes

No

Do you have intestinal gas? If so, when?

Do you, or have you ever struggled with alcohol or substance abuse?

Yes

No

How many days per week do you drink alcohol?

Have you ever used recreational drugs?

Yes

No

Do you, or have you ever used tobacco? (If so, for how long?)

Are you exposed to secondhand smoke regularly?

Yes

No

Do you have mercury amalgam fillings in your teeth? If so, how many?

Do you often get cavities?

Yes

No

Do your gums bleed?

Yes

No

Do you feel worse at certain times of the year? If so, when?

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

Yes

No

Do odors affect you? If so, which ones?

List your hobbies and leisure activities:

Do you exercise regularly? If so, how many times a week?

What type of exercise is it?

How many hours of sleep do you get a night?

How many times, if any, do you wake up during the night?

How many times a night do you wake up to urinate?

What time do you go to bed at night?

What time do you usually wake up in the morning?

How do you feel when you wake up in the morning?

Disclaimer

Christine DeDominicis IHP. Powered and secured by Wix

Information gained from this site, Healthy Habits Integrative Health, LLC. or any affiliates is for educational purposes only. It is not intended to treat or diagnose illness.

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