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Health Intake
Please fill this out and bring it with you or just wait and do it when you get there.
To print these pages go to the bottom of this page
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Name _____________________________________ Date _________________ |
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" X " if a current issue or need, "O" if a significant old problem that’s mended, “?” if not sure |
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Check box |
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MUSCULOSKELETAL |
Check box |
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SYSTEMIC (cont.) |
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1 |
Jaw area |
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35 |
Bursitis |
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2 |
Neck |
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36 |
Chronic Fatigue Syndrome |
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3 |
Back - Upper |
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37 |
Diabetes |
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4 |
Shoulder pain or restriction |
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38 |
Dyslexia |
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5 |
Shoulder Imbalance |
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39 |
Fibromyalgia |
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6 |
Chest pain or congestion |
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40 |
Immune and Endocrine System |
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7 |
Pectoral muscle pain |
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41 |
Osteoporosis |
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8 |
Upper arm |
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42 |
Reynauds Syndrome |
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9 |
Elbow or Forearm |
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43 |
Sleep problems |
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10 |
Carpal Tunnel Syndrome |
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44 |
Skin condition |
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11 |
Hands and wrists |
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45 |
Swelling |
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12 |
Thumb and 1st finger numbness |
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46 |
Trembling |
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13 |
Back - Middle |
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HEAD |
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14 |
Back - Lower |
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47 |
Bell’s Palsy |
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15 |
Loins (above hips) |
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48 |
Dizziness |
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16 |
Hips |
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49 |
Ear - infections, deafness, tinnitus |
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17 |
Walking problems |
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50 |
Eye and sight problems |
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18 |
Groin pain |
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51 |
Hair |
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19 |
Hernia - Inguinal |
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52 |
Headaches |
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20 |
Sacrum (spine above coccyx) |
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53 |
Migraines |
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21 |
Coccyx (tailbone) |
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54 |
Nose, palate |
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22 |
Sciatic nerve pain |
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55 |
Sinus conditions |
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23 |
Hamstrings or Quads |
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56 |
Teeth - grinding, crowding |
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24 |
Knees |
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57 |
Thyroid |
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25 |
Restless leg syndrome |
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58 |
Vertigo |
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26 |
Leg cramps |
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REPRODUCTIVE / URINARY |
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27 |
Calf or shin splints |
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59 |
Bladder infections |
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28 |
Ankles |
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60 |
Breast pain, cysts, mastectomy |
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29 |
Feet and Toes |
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61 |
Incontinence |
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30 |
Bunions |
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62 |
Conception - series |
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31 |
Plantar fasciitis |
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63 |
Uterine or ovarian |
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SYSTEMIC |
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64 |
PMS with breast tenderness |
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32 |
A.D.D. or A.D.H.D |
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65 |
PMS and menstrual symptoms |
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33 |
Adrenal exhaustion |
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66 |
Pregnancy - Due ____,_____,_____ |
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34 |
Arthritis |
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67 |
Pregnancy - during childbirth |
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Page 2 of intake FORM |
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Check box |
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REPRODUCTIVE / URINARY (cont.) |
Check box |
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RESPIRATORY |
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68 |
Pregnancy - post partum |
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96 |
Allergies |
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69 |
Menopausal / premenopausal |
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97 |
Asthma and other lungs issues |
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70 |
Prostate |
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98 |
Bronchitis |
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71 |
Sexual organs Female or Male |
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99 |
Colds |
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CIRCULATORY |
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100 |
Cough |
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72 |
Angina pain |
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101 |
Diaphragm pain / hiatal hernia |
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73 |
Blood impurities |
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102 |
Emphysema |
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74 |
Blood Pressure |
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103 |
Glandular fever |
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75 |
Cerebral Haemorrage / Stroke |
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104 |
Hay fever |
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76 |
Circulation |
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105 |
Pneumonia |
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77 |
Fever |
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106 |
Sore throat |
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78 |
Heart |
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107 |
Thrush |
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79 |
Kidney |
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108 |
Tonsillitis |
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80 |
Mononucleosis |
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SPIRIT |
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81 |
Varicose Veins |
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109 |
Depression |
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DIGESTIVE |
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110 |
Emotional Overload |
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82 |
Abdominal or ovarian stitch |
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111 |
Energy Stimulant |
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83 |
Abdominal pain |
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112 |
Mental Clarity |
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84 |
Constipation |
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113 |
Stress Control |
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85 |
Diarrhea, Hemorrhoids |
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114 |
Meridian specific |
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86 |
Digestive problems |
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115 |
Chakra specific |
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87 |
Diverticulosis / IBS |
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FOR CHILDREN |
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88 |
Gall Bladder |
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116 |
Colicy baby |
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89 |
Ileocecal valve |
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117 |
Bed Wetting - Series |
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90 |
Influenza - flu |
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118 |
A.D.D. / A.D.H.D. - Series |
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91 |
Liver |
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119 |
1st Birthday "FREE" |
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92 |
Indigestion, heartburn, nausea |
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120 |
any other issues |
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93 |
Nutrient assimilation |
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94 |
Pancreas |
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95 |
Weight issues |
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