Intake Form & Health Questionnaire Patient Intake Form (#1)First NameLast NamePatient AgePrefered Name / NicknamePatient Gender- Select -MaleFemaleOthersAre you pregnant or breast feeding?- Select -Not applicablePregnantBreastfeedingPhone no.Spouse NameWith whom do you live?Marital Status Married Unmarried otherMarital status(other)OccupationRetired? Yes NoDate of retirementDisability ? Yes NoDate of disabilityDo you smoke? Yes NoHow many years did you smoke?If you quit, when did you stop?Do you drink alcohol?- Select -YesNoDo you drink soda/pop?- Select -YesNoDo you drink coffee?- Select -YesNoDo you drink energy drinks?- Select -YesNoHow much or how little do you exercise?Do you sleep well?- Select -YesNoDo you wake up rested?- Select -YesNoAre your bowel movements...- Select -HardIncompleteSolidSoftLooseDiarrheaBloodyDo you have bowel movements once a day or at least once a week?- Select -Once a dayAt least once a weekOn a scale of 1 to 10, rate your overall stressWhat are your primary health goals?What are your primary physical goals?What are your primary spiritual goals?What are your primary emotional goals?Any other concerns? I have read and agree to the Terms and Conditions and Privacy PolicyElectronic SignatureDate / TimeSubmit Form
