New Patient Intake Form
First name

Last name


Date of Birth

Email address:

Phone number:

Primary problem you want to address:



List any prescription medications currently taken:

What is your blood type? (O, A, B, AB)

List nutritional supplements currently taken:

Difficulty focusing or concentrating

Body temperature low, often colder than others in the same room

slow rate of speech and/or requires others to speak slowly or repeat themselves often

Fall asleep when head hits the pillow

Trouble finding words

Poor handwriting

Slow starter in the morning

limp or flat hair that won't hold a curl

Poor hand-eye coordination or difficulty with directions

Poor memory, need to write things down, or walk into a room and forget why you're there

difficulty learning new information/skills, or lives in past and tells the same stories over and over

Trouble seeing someone else's point of view

Outer 1/3 of eyebrow thinning or absent;  or pencil-thin or penciled-on eyebrows

Sweats often or heavily or oily skin

Frontal headaches or headaches at base of skull

Night sweats, wake between 1 - 3 am, or wake up exhausted

Belches or burps after meals

Tans easily, dark skin even in winter months

Water retention or puffiness in fingers, toes, or cheeks

Swollen tongue with teeth marks around edges

Facial and/or back acne

# of times sick with flu, shingles, or other virus in your lifetime

# of times sick with ear infection, strep throat, staph, or other bacterial infection in your life

# of time you missed school or work 2 times or more per year from illness in past 10 years

toenail fungus

Spider veins, varicose veins, or hemorrhoids

low vitamin D on blood tests

yellow stains in armpits of white shirts

Eyebrows thinning from top to bottom

Intestinal gas, especially after consuming leafy green vegetables

Cherry-colored markings on skin (check chest, neck, underarms, and belly) How many do you count?

Constipation or straining during bowel movements

Stores fat mainly in mid-section

Bloating (in general or with certain foods)

Pebbles, or thin, ribbon-like stools

history of PCOS

Cravings for starches like potatoes, pasta, bread, rice, cereal

female: peach fuzz on cheeks or upper lip hair

female: heavy period, 5+ days, cramping, and/or PMS or migraines

# of times on an antibiotic in your life

Eczema or other patches of lighter skin color

Itchy, irritated, or dry skin

Eyebrows thick and bushy

Water retention in ankles, "sock rings" at the end of the day

Restless sleep, lots of dreaming, usually about home/work

Bags under eyes

Overheat easily during exercise often with very red face/cheeks

Jumps or startles easily

Cellulite formation or skin dimpling around buttocks, upper thighs, or arms

Hold body stiffly or rigidly, or can't support body and sags

Age spots or bronze discolorations on skin and/or many freckles

makes poor food choices when hungry, tired, or emotional

store fat mainly in hips, buttocks, or thighs

reduced appetite during day, may increase at night

frequent urination

How many cups of coffee do you drink per week?

How many cups of caffeinated tea do you drink per week?

How many alcoholic drinks do you have per week? (1 shot = 1 drink, 1 glass of wine = 1 drink, 1 beer = 1 drink)

How many days per week do you eat chocolate?

Any known food allergies or sensitivities?

If so, please name them:

Describe your sleep quality (terrible, poor, average, great)

How many nights per week do you sleep through the night without waking up?

Do you remember your dreams? Do you have nightmares?

Thank you for completing your New Patient Intake form. Our office will contact you this week to set up your consultation with Dr. Mike.
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