New Patient Intake Form
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First name

 
Last name

 
Address

 
Date of Birth

 
Email address:

 
Phone number:

 
Primary problem you want to address:

 
Height

 
Weight

 
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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