origin clinics new patient intake form · origin clinics new patient intake form the questions...

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Origin Clinics

3324 W. UNIVERSITY AVE. #344 GAINESVILLE, FL 32607 (352) 587-0587

Origin Clinics New Patient Intake Form

The questions found below are intended to help the physicians at Origin Clinics better understand your current and overall health and to assist your practitioner in identifying and addressing your health-related goals and concerns. Origin Clinics utilizes an integrative approach to complementary medicine, which means we do our best to include a picture of our patients as a whole person. To accomplish this goal you will find the following questions cover a wide variety of topics including physical, mental, and emotional state. We at Origin Clinics realize that the intake form below is extensive, and may be difficult to answer in its entirety – do your best to fill out the form as completely and honestly as possible. If there are questions you are unable to answer at this time but would like to discuss with your practitioner at your first or future visits, or if there is information you feel is relevant but was not covered by our intake form, please make a note under the “Additional Information” section found on the last page of this form. To make your appointment time as effective and efficient as possible, please bring this intake form as well as any other appropriate documentation with you to your appointment. The information provided on the pages below will help your practitioner create your personalized health care plan. From everyone here at Origin Clinics – we are looking forward to assisting you along your path to better health and wellness.

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GENERAL INFORMATION

Last Name: _________________________ First: _________________________ Middle Initial: ______

Gender: □ Male □ Female Birthdate: _______/_______/_______ Age: _______________ Address: _________________________________________________________________________ City: _____________________ State: ______________________ Zip: ________________ Telephone: Home (_____) ______-_____________ Work (_____) ______-_____________ ext. ____ E-mail: ___________________________________________________________________________ Employer: ________________________________ Occupation: ___________________________ Number of Hours worked in a week: ______ Social Security #: _______ - _____ - _______ Full time Student: □ Yes □ No If yes - School Name: _____________________________________ Education (Highest Degree Achieved): ___________________ Where: ___________________ Marital Status: □ Married □ Partnership □ Single □ Separated

□ Divorced □ Widowed □ Other_________________________ Live With: □ Spouse □ Partner/s □ Parents □ Children

□ Friends □ Alone □ Other _________________________

Emergency Contact: Name ______________________________ Phone _____________________ Relationship to Patient ______________________________________________

How did you hear about our practice? _________________________________________________________ If referred, name of referrer: _________________________________________________________________

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HEALTHCARE PROVIDERS

List those you see on a regular basis or have seen within the last 6 months.

Seeking One?

Primary Care Name __________________________________________ □ Y □ N OB-GYN Name __________________________________________ □ Y □ N Specialist Specialty ________________________________________ □ Y □ N

Name __________________________________________

Specialty ________________________________________ □ Y □ N Name __________________________________________

Chiropractor: Name __________________________________________ □ Y □ N L.M.T.: Name __________________________________________ □ Y □ N P.T.: Name __________________________________________ □ Y □ N Psychotherapist Name __________________________________________ □ Y □ N Personal Trainer: Name __________________________________________ □ Y □ N Midwife: Name __________________________________________ □ Y □ N

Other: Modality ________________________________________ □ Y □ N Name __________________________________________

Modality ________________________________________ □ Y □ N Name __________________________________________

May your practitioner contact these providers to ensure coordination of your care? □ Y □ N Do you have previous experience with acupuncture? □ Y □ N If so, who was your last practitioner? _______________________________________________ Where was the practice located? _______________________________________________

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CONTEXT OF CARE

For all the questions below you are not required to fill in all blanks provided.

What health concerns would you most like to address? List in order of severity/level of concern

1. ______________________________________________________________________________ What year did the concern start? _________________________ Have you received a diagnosis related to this concern? _________________________ What makes it feel better? e.g. Heat, Cold, Movement, Position _________________________ What make it feel worse? e.g. Heat, Cold, Movement, Position _________________________ 2. ______________________________________________________________________________

What year did the concern start? _________________________ Have you received a diagnosis related to this concern? _________________________ What makes it feel better? e.g. Heat, Cold, Movement, Position _________________________ What make it feel worse? e.g. Heat, Cold, Movement, Position _________________________

3. ______________________________________________________________________________


4. ______________________________________________________________________________


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What expectations do you have for the results from this first appointment with our clinic?

1. ______________________________________________________________________________

2. ______________________________________________________________________________

3. ______________________________________________________________________________

What are your long-term goals in working with our clinic?

1. ______________________________________________________________________________

2. ______________________________________________________________________________

3. ______________________________________________________________________________ What is your present level of motivation to address any underlying causes of your signs and symptoms? Circle

your motivation rated below from 0 to 10, 10 representing complete dedication.

0 1 2 3 4 5 6 7 8 9 10 If you have any behaviors or habits that you believe contribute in a positive way to your health concerns, list them below.

1. ______________________________________________________________________________

2. ______________________________________________________________________________

3. ______________________________________________________________________________ If you have any behaviors or habits that you believe contribute in a negative way to your health concerns, list them below.

1. ______________________________________________________________________________

2. ______________________________________________________________________________

3. ______________________________________________________________________________ Choose the one negative behavior from the list you just made above that you believe will be the most significant personal challenge to overcome.

1. ______________________________________________________________________________ What is your current level of satisfaction with the following aspects of your daily life? Circle your level of fulfillment

rated from 0 to 10 on the lifestyle categories listed below, with 0 representing no fulfillment and 10 representing significant fulfillment.

Career 0 1 2 3 4 5 6 7 8 9 10

Money 0 1 2 3 4 5 6 7 8 9 10

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Health 0 1 2 3 4 5 6 7 8 9 10

Romance 0 1 2 3 4 5 6 7 8 9 10

Fun & Recreation 0 1 2 3 4 5 6 7 8 9 10

Family 0 1 2 3 4 5 6 7 8 9 10

Friends 0 1 2 3 4 5 6 7 8 9 10

Physical Wellbeing 0 1 2 3 4 5 6 7 8 9 10

Environment 0 1 2 3 4 5 6 7 8 9 10

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MEDICAL HISTORY

If you need additional space for any of these tables use the “Additional Notes” section at the very end of this intake form.

Personal History Place a check box in the appropriate box if you have experienced or had issues with any of the following conditions:

□ Cancer □ Diabetes □ Seizures

□ Heart Disease □ High Blood Pressure □ Low Blood Pressure

□ Stroke □ Anemia □ Kidney Disease

□ Hepatitis □ Thyroid Imbalance □ Asthma

□ Eating Disorder □ Arthritis □ Ulcers

□ Alzheimer’s □ Auto-Immune □ Alcohol / Drug Addiction

□ Chronic Fatigue □ Blood Clotting Disorder □ Prolapsed Organ

□ Chronic Pain □ Fibromyalgia □ HIV / AIDS

□ Other

Give additional details about any of the conditions listed above, or other relevant western medical diagnoses.

Medical Diagnosis Onset (Date diagnosed) Treatment Received Date treated

List all major injuries, surgeries, or procedures you have had.

Injury, Surgery, Hospitalization, Etc.

Treatment Received Date treated

List all prescription pharmaceuticals you are currently taking or were taking within the last month.

Name of Medication Dosage Treating what Condition Frequency

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List all Over-The-Counter medications, supplements, herbal medicine, homeopathic, and natural remedies you are currently taking were taking within the last month.

Name of Medication Dosage Treating what Condition Frequency

List any pharmaceuticals, supplements, herbal medicines, or natural remedies that you have used in the last 2 years and the reason you stopped taking them.

Medication / Treatment Name

Treating what Condition Cessation Date (When did

you stop taking them) Reason for Stopping

List any allergies or sensitivities you have – including Foods, Medications, Environmental, Supplements, etc.

Medications Supplements / Herbs Food Environmental

(pollen, dander, etc.)

Do you now or have you ever used products containing nicotine? □ Yes □ No

If Yes

What product did you use? ___________________________________________________________ What year did you start? _____________________________________________________________ What year did you quit? _____________________________________________________________ How much per day? _____________________________________________________________

Do you now or have you ever regularly consumed alcohol? □ Yes □ No

If Yes

What year did you start? _____________________________________________________________ What year did you stop? _____________________________________________________________ How many drinks per week, on average, do / did you consume? ______________________________

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Do you now or have you ever used illicit substances? □ Yes □ No If Yes

What substances do you use? ________________________________________________________ What year did you start? _____________________________________________________________ What year did you quit? _____________________________________________________________ How much per day? _____________________________________________________________

Are you aware of any prolonged exposure recently or at any point in the past, to any of the following materials?

□ Heavy Metals □ Pesticides / Herbicides □ Radiation □ Radon □ Molds □ Asbestos □ Other Hazardous Material ____________________

Childhood Place a check box in the appropriate box if you contracted any of these conditions during your childhood. If you are uncertain but believe you may have experienced one or more of the conditions listed, mark the checkbox and mention this fact to your practitioner.

□ Scarlet Fever □ Diphtheria □ Rheumatic Fever □ Mumps

□ Measles

□ Polio

Have you had any negative reactions to immunizations? □ Yes □ No

If Yes

Which immunizations? _______________________________________________________ What year did this happen? _______________________________________________________

Family History Circle the appropriate abbreviation to indicate which, if any, of the following conditions that apply to your immediate family members. In the blank lines that follow the chart, please give any relevant additional details (for example, type of cancer, variety of genetic disorder, etc.)

Key: M = Mother PGm = Paternal Grandmother F = Father PGf = Paternal Grandfather S = Sister MGm = Maternal Grandmother B = Brother MGf = Maternal Grandfather Cancer M F S B PGm PGf MGm MGf High Blood Pressure M F S B PGm PGf MGm MGf Diabetes M F S B PGm PGf MGm MGf Heart Disease M F S B PGm PGf MGm MGf Stroke M F S B PGm PGf MGm MGf

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Asthma M F S B PGm PGf MGm MGf Seizures M F S B PGm PGf MGm MGf Genetic Disorder M F S B PGm PGf MGm MGf Infertility M F S B PGm PGf MGm MGf Chron’s / Colitis M F S B PGm PGf MGm MGf Alzheimer’s M F S B PGm PGf MGm MGf Tuberculosis M F S B PGm PGf MGm MGf Alcoholism M F S B PGm PGf MGm MGf Kidney Disease M F S B PGm PGf MGm MGf Other Condition M F S B PGm PGf MGm MGf Details: __________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

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REVIEW OF SYSTEMS

Fill in all check boxes of the symptoms you have experienced within the last 6 months.

General

Appetite Sudden Energy Drops Loss

Bleeding or Bruising Easily Thirst Sleep

or Swelling Balance Loss Sweats Weight Gain

in Appetite Skin & Hair

Ulcers Loss Moles

Head, Eyes, Nose, and Throat

Vision Ringing Problems

Problems Strain/Pain Blindness Hearing

Bleeds Pain Pain Aches in Front of Eyes Sore Throat or Tongue Sores

Cardiovascular

Blood Pressure Blood Pressure Heartbeat Hands or Feet Clots

of Hands of Feet Pain

Respiratory

Breathing Up Blood Breathing Winded

Gastro-Intestinal

Breath Pain

Laxative Use Gas Pain

in Stools Urology

Urination to Urinate to Hold Urine in Urine Flow Urination in Urine

Urine Stones Night Urination in Groin Area Transmitted Disease

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Neuro-Psychological

of Numbness of Coordination of Balance

Memory Swings

Gynecological

Year first menses occurred ________ Average duration of menses (days) _____ Time since last menses (days) __________________ Total # of Pregnancies _________ Total # of Births _________ # via Cesarean _____________

Periods Periods Lumps

Infections Discharge Problems

Musculo-Skeletal

Weakness Cramping Spasms Joints

with Weather Changes

Go to the next page to fill in the related pain diagram.

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PAIN DIAGRAMS

To label the locations - circle areas of ongoing pain, put an “x” on any areas with numbness, and next to each place a numerical pain value using the provided rating guide below. Pain Rating Scale

1 = Might be an itch 2 = Needs a bandage 3 = Somewhat annoying

4 = Concerning but able to focus 5 = Bees? 6 = BEES!

7 = Can’t stop crying 8 = Can’t move or focus 9 = Attacked by a bear

10 = Unconscious

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ADDITIONAL INFORMATION

Place any relevant details or additional information in the lines below.

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

origin clinics new patient intake form · origin clinics new patient intake form the questions...

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