Online Intake Form

General

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Poor appetite

Poor sleep

Fatigue

Fevers

Chills

Night Sweats

Sweat Easily

Tremors

Cravings

Localized weakness

Poor balance

Change in appetite

Bleed or bruise easily

Weight loss

Weight gain

Peculiar tastes or smells

Strong thirst (cold or hot drinks)

Chronic infections

Sudden energy drop?

What time of day does the sudden energy drop occur?

Skin and Hair

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Rashes

Ulcerations

Hives

Itching

Eczema

Pimples

Dandruff

Loss of hair

Recent moles

Head, Eyes, Ears, Nose And Throat

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Dizziness

Concussions

Migraines

Glasses

Eye Strain

Eye Pain

Poor Vision

Night Blindness

Color Blindness

Cataracts

Blurry Vision

Earaches

Ringin in the Ears

Poor Hearing

Ear Infections

Sinus Problems

Nose Bleeds

Spots in the eyes

Grinding Teeth

Sores on the tongue

Teeth/Gum Problems

Canker Sores

Recurrent Sore Throats

Mercury (silver) amalgams

Tonsilitis

Chronic swollen glands

# of Mercury (silver) amalgams

Cardiovascular

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

High Blood Pressure

Low Blood Pressure

Chest Pain

Irregular heartbeat

Dizziness

Fainting

Cold Hands or Feet

Swelling of Hands

Swelling of Feet

Blood Clots

Phlebitis

Difficulty in Breathing

Any other heart or blood vessel problems?

Please describe other heart or blood vessel problems.

Respitory

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Cough

Coughing Blood

Asthma

Bronchitis

Pneumonia

Pain with a deep breath

Difficulty in breathing when lying down

Production of phlegm

Gastrointestinal

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Nausea

Indigestion

Black Stools

Vomiting

Belching

Blood in Stools

Constipation

Gas

Rectal Pain

Diarrhea

Bad breath

Hemorrhoids

Abdominal pain or cramps

Chronic laxative use

Ulcers

Gallstones

Any other problems with your stomach or intestines?

Please describe other issue with stomach or intestines

Please Describe

Genito-Urinary

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Pain on Urination

Frequent Urination

Blood in Urine

Urgency to Urinate

Unable to Hold Urine

Kidney Stones

Gout

Decrease in Flow

Impotency

Pregnancy And Gynecology

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Unusual Menes

Clots

Painful periods

Irregular periods

Spotting or bleeding between periods

Vaginal discharge

Breast Lumps

Vaginal sores

Age at first menses

Please enter a value between 0 and 30.

Number of births

Please enter a value between 0 and 30.

Premature births

Please enter a value between 0 and 30.

First date of last menses

Abortions

Please enter a value between 0 and 30.

Number of pregnancies

Please enter a value between 0 and 30.

Days between menses

Please enter a value between 0 and 30.

Duration of menses

Please enter a value between 0 and 30.

Miscarriages

Please enter a value between 0 and 30.

Date of last PAP

Date of last Mammogram

Date of last Breast Self-Exam

Changes in body/psyche prior to menses

(please describe)

Have you had a hysterectomy?

Yes
No

Do you practice birth control?

Yes
No

What type?

For how long?

Have you ever been or are now being physically or sexually abused?

Yes
No

Neuropsychological

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

Seizures

Dizziness

Loss of balance

Areas of numbness

Lack of coordination

Poor memory

Concussion

Depression

Anxiety

Quick temper/irritable

Easily susceptible to stress

Panic attacks

Post traumatic stress disorder

Have you ever been treated for emotional problems?

Yes
No

Have you ever considered or attempted suicide?

Yes
No

Any other neurological or psychological problems?

Yes
No

Musculo-Skeletal

Please check if the following symptoms are currently a problem or are a recurring problem. Then rank the order in which they first occurred.

How Did You Hear About Our Clinic?

Which one?

Who?

Online Services

Online Intake Form

Intake Form

Step 1 of 6

Other Providers

Your Main Health Concern

Current Medications

Family History

Mental/Psychological Stresses:

Your Past Medical History

Diet

General

Skin and Hair

Head, Eyes, Ears, Nose And Throat

Cardiovascular

Respitory

Gastrointestinal

Genito-Urinary

Pregnancy And Gynecology

Neuropsychological

Musculo-Skeletal

How Did You Hear About Our Clinic?