Comprehensive Intake Form Page 2
ADVERTISEMENT
1
2
3
4Muscles:
cramps ( )
jerking ( ) bursitis ( )
Arthritis: kind if known:
Scoliosis
Recurrent dislocations: (list)
Any bone or joint Disease: (list)
Broken Bones: (list)
Other injuries
Head Injuries:
Loss of feeling/numbness/tingling
Paralysis
Convulsions/Seizures
Headaches
( )
Migraines
( )
Part Two: Digestive System & Abdomen
Appetite:
Poor ( )
excessive ( )
irregular ( )
Change in: Appetite ( )
eating habits ( )
nausea ( )
indigestion ( )
heartburn ( ) "nervous stomach" ( )
ulcers ( ) belching/burping ( )
gas/flatulence ( )
Abdominal: bloating ( )
pain ( )
Vomiting:
food ( ) blood ( ) bile ( )
Stools:
bloody ( ) black ( ) fatty ( )
diarrhea ( )
constipation ( )
Hemorrhoids:( )
bleeding ( ) piles ( )
Rectal bleeding
Parasites
( )
worms ( )
Liver problems ( ) Hepatitis ( )
Gall bladder problems ( ) Pancreas problems ( )
Ulcers
Hernia
abdominal ( ) hiatal ( ) inguinal ( )
Part Three: Heart and Circulation
Chest Pain ( ) pain over heart ( )
Heart Beat: rapid ( ) irregular ( ) slow ( )
Heart Palpitations
Other heart problems (describe):
Blood Pressure: high ( ) low ( )
Varicose veins
general swelling/edema ( ) ankles ( ) feet ( )
Pain in calf while walking
Part Four: Skin, Hair & Nails
Skin:
Itchy ( ) sensitive ( ) rash ( )
Bruise Easily
Perspiration: excessive ( ) deficient ( )
Nail Problems (describe):
Premature gray hair
Other hair/scalp problems (describe):
Part Five: Reproductive System
Vaginal: discharge ( ) excess bleeding ( ) pain ( )
Breast: discharge ( )
tenderness ( ) lumps ( )
Menstrual cramps
front ( ) back ( ) both ( )
Mood changes, menstrual cycle related
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business