Patient Intake Feature

 


Medical History:

Cancer

Diabetes

Hepatitis

Thyroid Disease

HIV / Aids

High Blood Pressure

Heart Disease

Seizures

Auto-Immune Disease

High Cholesterol

Venereal Disease

Infertility

Current or Past Tobacco Use

Allergies

Surgeries

Trauma/Accidents

Other Illnesses


General Symptoms:

Loss of Appetite

Insomnia

Difficulty Falling Sleep

Difficulty Staying Asleep

Frequent Thirst

Night Sweats

Fever

Chills

Weight Gain

Weight Loss

Easily Cold

Easily Hot

Bruise Easily

Poor Balance

Fatigue

Tremors

Food Cravings


Skin and Hair:

Rashes

Ulcerations

Hives

Dry Skin

Thinning Hair

Eczema

Acne

Itchy Skin

Oily Skin

Change in Hair Texture


Head, Eyes, Ears, Nose, Throat:

Dizziness

Convulsions

Migraines

Eye Floaters

Eye Pain

Difficulty Seeing at Night

Cataracts

Ear Pain

Ringing in Ear

Frequently Having to Clear Throat

Frequent Sore Throat

Voice Changes

Difficulty Swallowing

Nose Bleeds

Cold Sores

Facial Pain

Headaches

Sinus Congestion

Change in Vision

Change in Hearing

Dental Conditions


Cardiovascular:

Low Blood Pressure

High Blood Pressure

Chest Pain

Palpitations

Irregular Heartbeat

Fainting

Cold Hands or Feet

Edema


Respiratory:

Chronic Cough

Coughing Up Blood

Asthma

Bronchitis

Pneumonia

Excessive Phlegm/Mucous

Chronic Obstructive Pulmonary Disease

Shortness of Breath


Gastrointestinal:

Nausea

Vomiting

Diarrhea

Gas

Belching

Heartburn

Black Stools

Bloating

Hemorrhoids

Abdominal Pain

Constipation


Genitourinary:

Pain when Urinating

Frequent Urination

Blood in Urine

Urinary Urgency

Urinary Difficulty

Incontinence

Wake at Night to Urinate

Impotence

Genital Sores/Lesions


Fertility and Gynecologic:

Post Menopause

Perimenopause

Hot Flashes

Night Sweats

Difficulty Getting Pregnant (Infertility)

Menstrual Clots

Miscarriage(s)

Menstural Cramps

Premenstrual Syndrome

Breast Tenderness

Menstrual Headaches

Constipation Menstrual Related

Loose Stools Menstrual Related

Vaginal Discharge

Abdominal Bloating Menstrual Related

Water Retention Menstrual Related

Irritability Menstrual Related

Age of Menarche (First Menstrual Cycle)

Any Current Reproductive Health Therapies?

Number of Days Between Cycle?

Number of Days of Flow?

Heavy or Light Flow?

Changes in Menstrual Cycle?

Number of Children Born?


Musculoskeletal:

Back Pain

Back Pain at Night

Neck Pain

Shoulder Pain

Elbow Pain

Wrist Pain

Hand/Finger Pain

Hip Pain

Sciatica

Knee Pain

Ankle Pain

Foot/Toe Pain

Muscular Pain

Other Pain


Neuropsychological:

Depression

Anxiety

Frequent Mood Swings

Seizures

Dizziness

Loss of Balance

Poor Memory

Decreased Hand-Eye Coordination

Areas of Numbness

Current or Past Suicidal Thoughts

Previously Diagnosed Psychiatric Condition?


Cancer:

Current or Previous Cancer Diagnosis

Receive(d) Chemotherapy

Receive(d) Radiation

Surgery

Neuropathy Hands

Neuropathy Feet

Fatigue

Nausea

Dizziness

Change in Taste

Burning Tongue

Mouth Sores

Change in Nails

Hot Flashes

Hair Loss

Constipation

Loose Stools

Insomnia

Foggy Thinking

Pain

Type of Cancer

Date of Diagnosis

Other