Comprehensive Intake Form Page 3
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4Menopause problems ( )
Hot flashes ( )
Menstrual flow: heavy ( ) medium ( ) low ( )
Duration of period :
days
Length of cycle (start to start) :
days
Date of last period (1st day)
# of pregnancies:
Number of children:
Birth Control Method:
Currently sexually active:
Sexual difficulties (describe):
Genital Lesions
Hernia
Testicles: pain ( ) mass or lump ( )
Prostate problems
erection problems ( ) ejaculation problems ( )
Part Six: Kidney and Bladder
Urination: Painful ( ) Frequent ( ) difficult ( )
Hesitant/intermittent ( ) urgent ( )
Urination at night
Urine excessive ( ) scanty ( )
Urine discolored ( ) bloody ( ) strong odor ( )
infections ( ) discharge ( )
Loss of bladder control
Kidney Stones ( ) Other related problems:
Part Seven: Respiratory System
Breathing: difficult ( ) painful ( )
Shortness of breath: on exertion ( ) at night ( )
Persistent cough
Coughing: phlegm ( ) blood ( )
Wheezing or Asthma: on exertion ( ) at night ( )
Hyperventilation
Sinus congestion: not frequent ( ) chronic ( )
Part Eight: Eye, Ear, Nose & Mouth
Eyes: strain ( ) inflammation ( )
Blurred Vision
Other visual Problems (describe)
Ears: pain ( ) ringing ( ) discharge ( )
Loss of: Hearing ( ) Sight ( ) Taste ( ) Smell ( )
Nose: Pain ( ) bleeding ( ) discharge ( )
Difficulty breathing through nose: during day ( ) during night ( )
Sore Throat
Hoarseness
Difficulty with: swallowing ( ) speech ( ) chewing ( ) teeth ( )
Tongue problems (describe):
Mouth: ulcers ( ) bad taste in mouth ( )
Saliva: excessive ( ) deficient ( )
Part Nine: Miscellaneous
Have you ever been diagnosed as having: cancer ( ) diabetes ( )
hypoglycemia ( ) sexually transmitted disease ( )
Mono ( ) AIDS ( ) Epstein Barr ( )
Thyroid Problems: hypo ( ) hyper ( )
Other:
Rapid Weight gain ( ) loss ( )
Heat and cold intolerance ( ) cold hands and/or feet ( )
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