Self Heal New Patient Intake Form

Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All of your answers will be held absolutely confidential. If you have questions, please ask. If there is anything you wish to bring to our attention that is not asked on this form, please note it in the Comments section. 

Thank you very much.

Email *
Date *
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Name *
Date of Birth *
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Phone Number *
Email Address *
Physical Address *
Height *
Weight *
Place of Birth  *
Marital Status *
Primary Care Physician  *
Referred by
In Case of Emergency Notify *
Emergency Number *
Primary Problems you would like help with  *
How long ago did this problem begin? *
Have you been given a diagnosis for this problem? If yes what is the diagnosis? *
Have you been treated by Acupuncture or Oriental Medicine before? When? *
Have you used Homeopathy? What kinds of treatments have you tried? *
Please check all that apply. List all major infections:
Regarding the above : describe past medical history (please include dates) *
Have you been hospitalized for a serious illness or trauma? If yes please explain: *
Have you been hospitalized for mental or emotional illness? If yes please explain:  *
Have you been vaccinated? If so what Vaccinations? *
Significant Illnesses:  *
Required
Surgeries (describe types and dates): *
Describe any scars from surgery or injury: *
Have you had any blood transfusions? *
Significant Traumas (Auto Accidents, falls, injuries, etc.): *
Allergies (drugs, chemicals, foods, etc.): *
Required
Family Medical History:  *
Required
Other Medical Problems that run in your family?  *
Describe any significant problems associated with your mother's pregnancy with you:  *
Describe any problems with your birth:  *
Regarding the above question:  *
Required
Medications: taken within the last 2 months including vitamins, drugs or herbs:  *
Check any of the following medications you have used in the past, for any extended period of time:  *
Required
Travel, long visits or lived in foreign country like Mexico, India, Africa, etc?  *
Current Occupation *
Stressful job? *
Like your job and work environments? *
Live or work near power lines, transformer, lots of computer time? *
Is your job associated with potentially harmful chemicals? *
Chemical or Pesticide exposure current or past / use of strong chemicals in your home:  *
Required
Do you have a regular exercise program? *
Do you feel unusually fatigued after exercise? *
Does your present physical condition limit your physical activity? *
I feel less/more vital than I did one year ago? *
Stress is currently reducing my quality of life?  *
I practice a form of stress reduction (yoga, meditation, etc.) *
Rate your stress level *
My life has meaning and purpose *
I feel happy *
Diet & Nutrition - please describe your average daily diet (breakfast, lunch, dinner, snacks) *
My appetite is:  *
I prefer drinks *
I crave foods that are:  *
Check all that apply to you:  *
Required
I use artificial sweetners *
Required
I am on a special or restricted diet:  *
Required
I react adversely to some foods. If yes, please explain. *
I smoke or chew tobacco. If yes, list types and quantity per day  *
I use coffee, tea, caffeine, chocolate or cola. If yes, list quantity per day *
I react adversely when I consume caffeine. If yes, please explain. *
I drink alcohol. If yes, list quantity per day/week *
I use recreational drugs. If yes, list types and frequency. *
I react adversely to the following (check all that apply):  *
Required
I am bothered by video display terminals and/or florescent lights:  *
I get 6-8 hours of sleep per night
Clear selection
Dental intervention (list all that apply): *
Please Check if you have had the following in the last 3 months:  *
Required
Please elaborate on any of your answers above: *
Is there a sudden drop in energy at a particular time of day? *
Overall Energy Level: *
Skin Hair  *
Required
Head, ears, eyes, nose & throat:  *
Required
Cardiovascular *
Required
Respiratory *
Required
Gastrointestinal *
Required
Number of bowel movements per day *
Genito-Urinary *
Required
Reproductive and gynecologic 
Number of pregnancies *
Number of births *
Number of Abortions *
Number of Miscarriages  *
Age of first menes *
Date of last menses
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DD
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Last pap
MM
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DD
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Time between menses and duration
Are you pregnant *
Menopause, if yes what age?
Hysterectomy
Clear selection
Hormone replacement
Clear selection
Do you practice birth control, if so what type and for how long: 
Men
Musculoskeletal *
Required
Neuropsychological  *
Required
Mental Emotional *
Required
My emotions are:  *
I have been treated for emotional problems, if yes please describe  *
I have considered or attempted suicide, if yes please elaborate  *
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