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    NEW PATIENT INTAKE

    Patient Health History

    *All information will be kept strictly confidential. Your responses will allow us to get a more complete picture of your health, uncover contributing factors to your chief complaint(s) and advise you in your health goals. Thank you for investing in your health. We look forward to supporting you!

    Address








    Married? YesNo

    Children? YesNo

    Children's Names and Ages:


    Please mark all conditions, past and present, even if they are only occasional:


    Neck PainPastPresent

    Arm painPastPresent

    Elbow painPastPresent

    Wrist/Hand painPastPresent

    Upper back painPastPresent

    Lower back painPastPresent

    Hip painPastPresent

    SciaticaPastPresent

    ScoliosisPastPresent

    Leg painPastPresent

    Knee painPastPresent

    Ankle/Foot painPastPresent

    TMJ/Jaw painPastPresent

    HeadachePastPresent

    MigranePastPresent

    ArthritisPastPresent

    Chronic fatiguePastPresent

    NervousnessPastPresent

    DepressionPastPresent

    Twitches/TremorsPastPresent

    Rapid/Skipping heartbeatPastPresent

    InsomniaPastPresent

    Poor digestionPastPresent

    Heartburn/acid refluxPastPresent

    Gas/BloatingPastPresent

    ConstipationPastPresent

    DiarrheaPastPresent

    HemorrhoidsPastPresent

    DiabetesPastPresent

    CancerPastPresent

    Heart diseasePastPresent

    Irritable bowel/ColitisPastPresent

    Crohn’s/CeliacPastPresent


    NauseaPastPresent

    Stomach painPastPresent

    Poor appetitePastPresent

    Excessive hungerPastPresent

    VomitingPastPresent

    Allergies/HayfeverPastPresent

    Cold soresPastPresent

    Sinus problemsPastPresent

    AsthmaPastPresent

    Earache/Ear infectionsPastPresent

    Colds/Flu/BronchitisPastPresent

    High blood pressurePastPresent

    Low blood pressurePastPresent

    Cold hands & feetPastPresent

    Bed-wettingPastPresent

    Frequent urinationPastPresent

    Prostate troublePastPresent

    Ringing in earsPastPresent

    Skin problemsPastPresent

    Varicose veinsPastPresent

    Eye problemsPastPresent

    Throat problemsPastPresent

    Thyroid problemsPastPresent

    Menstrual problemsPastPresent

    Fibrocystic diseasePastPresent

    Weight problemPastPresent

    Venereal diseasePastPresent

    AlcoholismPastPresent

    Drug AbusePastPresent

    Please indicate any conditions, past or present, of any FAMILY MEMBERS:

    Health Issue

    Relation to you

    Allergies

    Anxiety

    Asthma

    Back trouble

    Bowel trouble

    Cancer

    Depression

    Diabetes

    Epilepsy

    Health Issue

    Relation to you

    Headaches

    Heart disease

    High blood pressure

    Hormonal imbalance

    Indigestion

    Insomnia

    Scoliosis

    Sinusitis

    Skin Issues

    Other

    Please describe the quality of your:

    1 = Terrible, 10 = Terrific

    Sleep

    12345678910

    Energy

    12345678910

    Typical mood

    12345678910

    Digestion

    12345678910

    Job

    12345678910

    Physical home environment

    12345678910

    Physical work environment

    12345678910

    Parental relationships

    12345678910

    Friend relationships

    12345678910

    Romantic relationships

    12345678910

    Exercise

    12345678910

    Food

    12345678910

    Water

    12345678910

    Rest and Relaxation

    12345678910

    Spiritual life

    12345678910

    Do you take: Birth control pillAspirin/Ibuprofen/etc.Antacid

    Do you take:Vitamins/MineralsHerbsHomeopathicsProbiotics

    Please indicate all of the following habits:

    AlcoholNoneModerateHeavy

    Coffee/Black teaNoneModerateHeavy

    TobaccoNoneModerateHeavy

    MarijuanaNoneModerateHeavy

    SugarNoneModerateHeavy

    SaltNoneModerateHeavy

    Coke/Pepsi/etc.NoneModerateHeavy

    Margarine/Crisco/etc.NoneModerateHeavy

    Cold cutsNoneModerateHeavy

    Fried FoodsNoneModerateHeavy

    BarbecueNoneModerateHeavy

    Artificial SweetenersNoneModerateHeavy

    Artificial colorings & flavoringsNoneModerateHeavy

    Please describe your typical meals:




    Who do you know (friends or family members) that have health issues that you are concerned about?

    Name

    Contact Information

    (We appreciate your referrals. Refer a friend & receive a discount of 20% off your next visit with Dr. Martin.)