Comprehensive Intake Form printable pdf download

Comprehensive Intake Form

The Applied Kinesiology Center

Comprehensive Form

Confidential Health Questionnaire

Name__________________

Date___________

Mark severity in past/now box from 1 to 3. (1-slight 2-moderate 3-severe)

please check box ( ) where appropriate.

Statistics:

Height:

Weight: now:

; one year ago:

;maximum:

when?

Surgery: ovaries/uterus ( ) gallbladder ( ) appendix ( ) other ( )

Have you ever had X-rays of: back ( ) neck ( ) extremities ( ) organ ( )

other ( )

Have you ever had a MRI/CTScan?

Favorite Foods:

Allergies: Food or other:(list)

What foods do you crave and when?

Do You Use….

Never Rarely Freq.

Daily

Vitamins

Laxatives

Sedatives/tranquilizers

Sleeping pills/Aids

Aspirin, etc.

Appetite drugs:

Alcoholic Beverages

Coffee/Tea cups per day:

Soft Drinks

Cigarettes packs per day:

Cigars/Pipes ( ) Chewing tobacco ( )

Recreational Drugs: Marijuana ( ) Other ( )

Have you EVER tried any recreational drugs?

Current Supplements/Medications (List)

Medications:Please include: Name/Reason for taking/Duration:

Vitamins/Minerals/Herbs:(list)

Part One: Musculo-Skeletal & Nervous System

Past

Now

Muscles:

Sore ( )

aching ( )

weak ( )

tight ( )

Comprehensive Intake Form

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