Intake & Health History Form
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
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Adjuster's Name
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Policy Number
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Office Address
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Unit #
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City
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Country
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Prov / State
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Postal Code / Zip
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Phone
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Fax
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Email Address
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Claims / Benefit
Conditions
Treatment Goals
Improve Lifestyle
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Pain Relief
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Stress Relief
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Support in Healing/Recovery
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Rehabilitation
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Health Advice for Healing
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Improve Well Being
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Improve Symptoms
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Other
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Male Health
Urinary Stream Changes
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Painful Urination
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Difficulty Maintaining Erection
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Nocturnal Urination
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Difficulty Obtaining Erection
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Family History of Prostate Disease
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Painful Ejaculation
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Family History of Prostate Cancer
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History of Back Injury
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History of STD
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PSA Test Results
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Difficulty Experiencing Orgasm
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Sperm Count Results
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Well Being
Hobbies
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Smoking
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Interests
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Caffeine
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Exercise
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Sports
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Mobility/Walking Aids
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Flexibility
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Range of Motion
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Drinking
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Energy Level
Clear
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High
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Even
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Agitated
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Flat
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Chaotic
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Low
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Fatigue
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Dull
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Vibrant
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Infectious
Lyme Disease
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Strep
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Epstein Barr
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Pneumonia
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TMJ (Jaw)
Morning Stiffness
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Ear Ringing
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Grinding
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Ear Stuffiness
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Jaw Pain
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Ear Pressure
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Clicking
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Ear Blockage
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Locking
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Difficulty Opening Jaw
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Difficulty Chewing
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Clenching
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Energy
How long do you sleep on average?
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Do you struggle with insomnia?
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Does your energy fluctuate?
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Is your energy constant?
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When is your energy highest?
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When is your energy lowest?
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What is your energy level upon awakening?
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Emotion / Memory
Substance Use Disorder
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Alzheimer Disease
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Anxiety Disorder
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Mood Disorder
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Schizophrenia
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Stress
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Feet
Pes Planus (Flat Feet)
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Pes Cavus (High Arch)
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Onychauxis
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Hallux Valgus
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Bunions
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Onychoptosis (Nail Loss)
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Overlapping Toes
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Onychomycosis (Nail Fungus)
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Corns/Callouses
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Involuted Nails (Curved/Pinched)
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Itchy or Peeling Skin
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Thickened Nails
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Dry/Cracked Skin
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Yellow Nails
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Heel Fissures
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Onychocryptosis (Ingrown Nail)
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Previous Amputations
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Female Health
Severe Menstrual Pain
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PMS
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Menopause
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Hysterectomy
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First Period
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Last Period
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Number of Pregnancies
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Number of Live Births
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Last PAP test
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Abnormal PAP test
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Irregular Periods
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Menstrual Cycle Length
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Menstrual Period Length
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Menstrual Cramping
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Heavy Bleeding
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Endometriosis
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Infertility
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Unwanted hair growth
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Premenstrual Syndrome
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Breast Cancer
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Ovarian Cancer
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Osteoporosis
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Current Menopausal Concerns
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Currently Pregnant
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Birth Control Method
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Implants
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Fibroids
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PCOS
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Uterine Polyps
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Spotting
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Dark Blood
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Clots
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Brown Spotting
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Pencil Like Stool
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Heaviness in Pelvis
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Urinary Incontinence
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Pelvic Organ Prolapse
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Pelvic Floor Injury
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Scar Tissue
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Pelvic Pain
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Pain with Sex
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Mouth Sores
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Lymph Nodes
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Enlarged Spleen
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Enlarged Liver
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Radioactivity
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Brain Disorders
Bulimia Nervosa
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Schizophrenia
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Anorexia Nervosa
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Antisocial Personality Disorder
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Claustrophobia
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Sleep Disorder
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ADD
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Depression
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Social Anxiety Disorder
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ADHD
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Generalized Anxiety Disorder
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Autism
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Obsessive Compulsive Disorder
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Asperger Syndrome
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Obsessive Compulsive Personality Disorder
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Bipolar Disorder
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Panic Disorder
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Acute Stress Disorder
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Borderline Personality Disorder
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PTSD
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Agoraphobia
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Headaches
Cluster
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Migraines
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Rebound
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Headaches
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Musculoskeletal
Osgood-Schlatter Disease
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Dupuytren's Contracture
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Jaw Pain (TMJD)
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Muscular Dystrophy
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Joint Stiffness / Swelling
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Chronic Myofascial Pain Syndrome
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Osteomalacia
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Myasthenia Gravis
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Spasms / Cramps
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Chronic Fatigue Syndrome
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Ankylosing Spondylitis
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Paget Disease
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Osteoporosis
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Whiplash
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Bone Disease
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Psoriatic Arthritis
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Torticollis
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Temporomandibular Joint Dysfunction
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Tendonitis/Bursitis
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Osteoarthritis
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Compartment Syndrome
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Gout
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Scleroderma
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Baker's Cyst
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Sinus Problems
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Spondylolisthesis
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Dislocation
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Fracture
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Scoliosis
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Recti Diastasis
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Artificial Joints / Special Equipment
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Hereditary/Congenital Deformity
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Strain/Sprain
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Broken Bone / Fracture
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Degenerative Disk Disease
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Ehlers-Danlos Syndrome
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Joint Injury
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Arthritis
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Plantar Fasciitis
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Amyotrophic Lateral Sclerosis (ALS)
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Bone or Joint Disease
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Fibromyalgia
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Carpal Tunnel Syndrome
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Other Musculoskeletal
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Gastrointestinal
Diverticulitis
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Acid Reflux
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Digestive Conditions
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Ulcerative Colitis
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Eating Disorder
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Hiatal Hernia
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Esophageal Disorder
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Stomach Disorders
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Gastroparesis
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Crohn's Disease
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Fecal Impaction
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Intestinal Gas/Bloating
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Intestinal Polyps
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Adaptive Aids
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Celiac Disease
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Irritable Bowel Syndrome
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Constipation
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Poor Appetite
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Diarrhea
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Abdominal Hernia
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Stomach Disorder
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Other Gastrointestinal
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Blood
HIV/AIDS
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Hepatitis
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Blood Thinner Medication
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Hypercoagulability
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Haemophilia
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HIV
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Stroke
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Polycythemia
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Fainting Spells
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Thrombosis/Embolism
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High Cholesterol
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Anemia
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Bleeding Disorder
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Other Blood
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Skin
Athletes Foot
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Rosacea
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Chemical Burn
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Athlete's Foot
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UV Burn
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Moles
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Hypersensitive Reactions
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Herpes
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Hypersensitive Reaction
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Cosmetic Surgery
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Eczema
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Melanoma/Carcinoma
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Severe Irritability
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Bruise Easily
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Pigmentary Disorder
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Non-Surgical Scars
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Plantar's Wart
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Surgical Scars
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Which State?
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