Step 1 of 3 33% ALPPHA'S HOLISTIC INTAKE FORM Contact InformationFull Name First Last Age Date of Birth MM slash DD slash YYYY Gender Male Female Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Home PhoneWork PhoneCell PhoneEmergency Contact Relationship PhoneMedical Doctor Name PhoneDoctor Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you become aware of Alppha's Holistic Healthcare: Health Goals / ConcernsWhat main health goal/concern brought you to the clinic today?How long have you had it? Describe any factors you suspect may have played a role in the onset and perpetuation of your condition:Previous practitioners consulted for this condition: MD ND Please explain their diagnosis, therapy and results where applicable:What type of therapy have you tried for this problem? Diet Modification Acupuncture Vitamin/Mineral Supplements Conventional Drugs Herbs Osteopathy Homeopathy Chiropractor Other What makes it better? What makes it worse? Please list any other health concerns or goals in order of importance: Personal Information/Lifestyle:Do you identify as: Straight Homosexual Bi-sexual Trans-gendered Other Marital Status: Single Married Separated Widowed With Partner Number of Dependants Occupation: Shift Work? Yes No Do you enjoy your work? Yes No Sometimes Is your job associated with potentially harmful chemicals (e.g. pesticides, solvents, radioactivity) or health and/or life threatening activities (e.g. firefighting, mining, etc.)? Please specify:Hours/Day you spend:Working: Driving: Watching TV: computer/screen: Circle the level of stress you presently experiencing in life. (10=highest) 1 2 3 4 5 6 7 8 9 10 Please list the major causes of stress for you: (Work, Finances, Relationship, Health, etc.)Have you experienced any major trauma, loss, or life changing significant events?Have you worked with a counsellor, psychologist, or psychiatrist? No Currently In the past Medical History:How would you describe your general state of health? Excellent Good Fair Poor Do you wear a medical alert bracelet/Tag? Yes No For what condition? What is your blood type? Do you wear? Corrective Lenses Dentures Hearing aid Medical devices/Prosthetics/Implants None For the following tables, (add more line if needed) Medical Conditions: Please indicate any Hospitalizations, Surgeries and Injuries you have experienced: Hospitalization/Surgery/InjuryDateSymptomsCondition Resolved X-rays, CT Scans, EKGs, ECCs, MRIs, or other imaging scans you've had in the past: Scan/Screen/TestDateReasonResult Allergies and or Food Sensitivities: Allergy/SensitivitySymptomsTreatment/Avoidance Current medications or supplements: Please list all medications or supplements you take on a regular basis: Medication/SupplementDose (if known)length of usePrescribing PractitionerAre you taking presently? Screening Tests: Please indicate when you had the following screening tests (if known): Screen/TestYear Screen/TestYear PAP (Females)Year DEXA ScreenYear PAP (Females)Year DEXA ScreenYear PAP (Females)Year DEXA ScreenYear PAP (Females)Year DEXA ScreenYear *Please bring a copy of any test results you have to your first visit.MammogramYear *Please bring a copy of any test results you have to your first visit.Other Diet and Health Habits: General energy level out of 10 ( 1=lowest, 10=highest):Please enter a number from 1 to 10.What time of day is it the highest? The Lowest? What time of day do you eat the following: Breakfast : Hours Minutes AM PM AM/PM Lunch: : Hours Minutes AM PM AM/PM Dinner: : Hours Minutes AM PM AM/PM
