Therapy Intake Form - Health Equations
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health equation
I N TAKE FORM
Name
Date
Occupation
Age
Sex
D.O.B.
Blood Pressure
Pulse
Blood Type
Please circle words or check boxes for whatever applies to you; fill in blanks.
Water, Salt, Energy, Stress:
◆
My current salt use is- l o w, moderate, heavy, by taste
Number of glasses of water each day _ _ _ _ _ _ _
I have never used much or any salt- Tru e or F a l s e
I crave salt and/or salty foods- Tru e or F a l s e
I previously used salt more than now- Tru e or F a l s e
I have unquenchable thirst-
Tru e or F a l s e
I have followed a low salt diet for _______ years.
I sweat ... a-lot, moderately, very little, not-at-all
Average energy level on a scale of 1 to 10 ______
Average stress level on a scale of 1 to 10 ______
❑
❑
❑
❑
Family History:
cardiovascular disease
adult onset diabetes
thyroid disease
o s t e o p o r o s i s
◆
Milk Intolerance: (circle one) Y
N
◆
Number of TOTAL pounds lost throughout your life dieting ________.
◆
N u m b e r of silver/amalgam fillings, currently _ _ _ _ _ _ _ _ , removed _ _ _ _ _ _ _ _ .
◆
N u m b e r of root canals, currently _ _ _ _ _ _ _ _ , removed _ _ _ _ _ _ _ _ .
◆
E x p o s u re to heavy metals, chemicals, dust, infections, radiation, plastics:
___________________________
◆
___________________________________________________________________________________
Women Only
Men Only
◆
◆
Number of childbirths ________
Prostate enlargement?
Y
N
Number of years nursing ________
Elevated PSA?
Y
N
Menstrual-related symptoms ______________________
Urination difficulties?
Y
N
______________________________________________
Perimenopausal years ________
Nighttime urination?
Y
N
Menopausal years ________
Sexual difficulties?
Y
N
Menopausal symptoms ___________________________
______________________________________________
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Parent category: Business