SOUL CENTERED HEALING

CLIENT INTAKE FORM

Print, fill out, then mail to Soul Centered Healing

All information will be kept confidential

 

Patient Name: ______________________________ Today's Date: __________________

Date of Birth: ____ / ____ / ______  Age: _____

Address: ________________________________________________________________

City: ____________________________ State: _________ Zip: _______________

Home Phone: __________________________ Cell phone: ________________________

Email address: __________________________________________

Children's Names & Ages: __________________________________________________

Occupation: __________________________ Employer: __________________________

Work Phone: ________________________

Marital Status: single married ______ years widowed separated divorced remarried

Name of Spouse/Partner: _____________________

Person to contact in case of emergency:

Name: ____________________ Relationship: _______________ Phone: ____________

How did you hear about us? ________________________________________________

What is your major complaint or condition you want to improve?

________________________________________________________________________

What is the beginning date of your injury or illness: ___________

Has there been a medical diagnosis?  yes no

Please explain: ___________________________________________________________

________________________________________________________________________

List any diagnostic procedures or tests you have had done for this condition (x-rays, EKG's, blood tests, etc.):

________________________________________________________________________

________________________________________________________________________

List any other conditions you would like to address: _____________________________

________________________________________________________________________

________________________________________________________________________

List any present medications with dosages you take every day:

________________________________________________________________________

________________________________________________________________________

List any medications you take only as needed (herbs, vitamins, supplements, over-the-counter drugs, etc.):

________________________________________________________________________

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HOSPITAL STAYS, SURGERIES, AND EMERGENCY ROOM VISITS

(childhood and adult - surgery, observation, etc.) - Please list chronologically from the first:

Date in hospital or

your age

______________________

______________________

______________________

   Reason for hospital stay

 

_________________________________________________

_________________________________________________

_________________________________________________

List any life-threatening accidents or illnesses:

Date or age

______________________

______________________

______________________

    

___________________________________________________

___________________________________________________

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List allergies of any kind: __________________________________________________

________________________________________________________________________

How would you describe your health as a child? excellent good fair poor

If fair or poor, please explain: _______________________________________________

Were there any complications during your mother's pregnancy with you, your birth or soon

thereafter?  yes  no

If yes, please explain: ______________________________________________________

________________________________________________________________________

 

 

 

 

MEN ONLY:

Check any that apply to you in the past (P) or currently (C):

 P   C

    Prostate troubles

    Penis: discharge/burning/itch/warts/herpes

    Testicles: swelling / lumps / pain

    Loss of desire / drive

    Difficulty keeping erection

 P   C

    Too early ejaculation

    Fertility concerns

    Contraception used: ______________

    Vasectomy _____ / _____ / _____

    Sexually transmitted disease

 

WOMEN ONLY:

Are you pregnant? yes no possibly

Age when menstrual periods started _______ Date of last period _____ / _____ / _____

Cycle: every _____ days     Duration: _____ days

Blood color is light red red dark red purple

Blood consistency is thin normal thick clots

Blood flow is light moderate heavy

Do you have cramps, back pain, headaches, irritability or any other symptoms associated with your periods?

Please explain:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Check any that apply to you in the past (P) or currently (C):

 P   C

    Pelvic inflammatory disease

    Endometriosis

    Sexually transmitted disease

    Herpes

    Warts

    Recurring infections

    Breasts: lumps / discharge or bleeding

 

 P   C

    Spotting between periods

    Fibroids

    Painful intercourse / bleeding after

    Vaginal discharge

    Vaginal dryness

    Hot flashes

    Fertility concerns

Number of pregnancies ____ Living children ____

Caesarean sections ____ Miscarriages ____

Abortions _____ Age of menopause _____ Hysterectomy date ____ / ____ / _____

Your last pap smear _____ / ____ / _____ result: _______

Your last mammogram (ultrasound)  ____ / ____ / _____ result: _______

Birth control method is: not having intercourse / rhythm / the pill / IUD / tubule ligation / diaphragm / condom / partner vasectomy

 

Check any of the following that apply to you in the past (P) or currently (C):

Musculo-Skeletal

 P   C

  Headaches

  Joint stiffness/swelling

  Spasms/cramps

  Broken/fractured bones

  Strains/sprains

  Back, hip pain

  Chest, ribs, abdominal pain

  Problems walking

  Jaw pain/TMJ

  Tendonitis

  Bursitis

  Arthritis

  Osteoporosis

  Scoliosis

  Bone or joint disease

  Other: __________________

 

Digestive System

 P   C

  Nervous stomach

  Indigestion

  Constipation

  Intestinal gas/bloating

  Parasites

  Diarrhea

  Diverticulitis

  Irritable bowel syndrome

  Crohn's Disease

  Colitis

  Other: __________________

 

Urinary

 P   C

  Burning upon urination

  Frequent urination

  Difficult/painful urination

  Blood in urine

  Urinary infections

  Kidney/urinary stones

  Incontinence

  Bladder infection

 

Nervous System

 P   C

  Numbness/tingling

  Twitching of face

  Fatigue

  Chronic pain

  Sleep disorders

  Ulcers

  Paralysis

  Herpes/Shingles

  Cerebral palsy

  Epilepsy

  Chronic Fatigue Syndrome

  Multiple Sclerosis

  Muscular Dystrophy

  Parkinson's Disease

  Spinal cord injury

  Other: __________________

Circulatory and Respiratory

 P   C

  Angina

  Chest pain

  Heart murmur

  Dizziness

  Shortness of breath

  Fainting

  Cold feet or hands

  Cold sweats

  Swollen ankles

  Pressure sores

  Varicose veins

  Blood clots

  Stroke

  Heart condition

  Allergies

  Sinus problems

  Asthma

  High blood pressure

  Low blood pressure

  Lymph edema

  Other: __________________

 

Skin

 P   C

  Rashes

  Allergies

  Athlete's foot

  Warts

  Moles

  Acne

  Cosmetic surgery

  Other: __________________

 

Other

 P   C

  Loss of appetite

  Unexplained weight gain/loss

  Forgetfulness

  Confusion

  Depression

  Mental/emotional disorder

  Difficulty concentrating

  Drug use ___________________

  Alcohol use _________________

  Caffeine use _________________

  Nicotine use _________________

  Hearing impaired

  Visually impaired

  Eating disorder

  Diabetes

  Fibromyalgia

  Cancer

  Chicken pox

  German measles

  Polio

  Rheumatic fever

  Scarlet fever

  Measles

  Mononucleosis (mono)

  Pneumonia

  Hepatitis (type? _____)

  AIDS or HIV+

  Infectious disease (please list)

 ______________________________

  Other congenital or acquired

disabilities (please list)

 ______________________________

 

Please list any additional comments regarding your health and well-being:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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Print, fill out, and mail to:

Soul Centered Healing

P.O. Box 1061

Great Barrington, MA 01230

 

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