Comprehensive Intake Form (Page 4 of 4) in pdf

Comprehensive Intake Form Page 4

Slow to heal ( )

Excessive thirst ( ) Water retention ( ) Swollen glands ( )

Tire easily ( ) general fatigue ( )

Poor memory/concentration/thinking

dizziness ( ) fainting ( ) fever ( ) chills ( )

Night sweats ( )

shaky feeling ( )

confusion ( ) irritable ( ) depression ( )

anxiety ( )

Emotional crisis/breakdown ( )

Do you cry easily ( )

Anemia

Dehydration

Part Ten: Personal Habits

Do you sleep well?

Awaken rested?

Average hours of sleep per night:

Bowel movements per day:

Diarrhea ( ) Constipation ( )

Sex - entirely satisfactory?

Do you like your work?

How many hours per day/week

Hours of Television you average per day:

Average time you read each day:

Average time with a computer:

Have you ever been treated for: Alcoholism ( ) Drug abuse ( )

Do you exercise?What/How often:

Hobbies:

Part Eleven: Family History

Spouse Mother Father Siblings Children

Check All Applicable and describe:

Cancer

Tuberculosis/TB

Diabetes

Heart Trouble

High Blood Pressure

Stroke

Epilepsy

Emotional Crisis

Asthma, hives, hayfever

Other

Death (list cause and year)

Comprehensive Intake Form Page 4