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M T & F: 9am - 5pm, W & Th: 1pm - 6pm

    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 Pain PastPresent
    Arm pain PastPresent
    Elbow pain PastPresent
    Wrist/Hand pain PastPresent
    Upper back pain PastPresent
    Lower back pain PastPresent
    Hip pain PastPresent
    Sciatica PastPresent
    Scoliosis PastPresent
    Leg pain PastPresent
    Knee pain PastPresent
    Ankle/Foot pain PastPresent
    TMJ/Jaw pain PastPresent
    Headache PastPresent
    Migrane PastPresent
    Arthritis PastPresent
    Chronic fatigue PastPresent
    Nervousness PastPresent
    Depression PastPresent
    Twitches/Tremors PastPresent
    Rapid/Skipping heartbeat PastPresent
    Insomnia PastPresent
    Poor digestion PastPresent
    Heartburn/acid reflux PastPresent
    Gas/Bloating PastPresent
    Constipation PastPresent
    Diarrhea PastPresent
    Hemorrhoids PastPresent
    Diabetes PastPresent
    Cancer PastPresent
    Heart disease PastPresent
    Irritable bowel/Colitis PastPresent
    Crohn’s/Celiac PastPresent

    Nausea PastPresent
    Stomach pain PastPresent
    Poor appetite PastPresent
    Excessive hunger PastPresent
    Vomiting PastPresent
    Allergies/Hayfever PastPresent
    Cold sores PastPresent
    Sinus problems PastPresent
    Asthma PastPresent
    Earache/Ear infectionsPastPresent
    Colds/Flu/Bronchitis PastPresent
    High blood pressure PastPresent
    Low blood pressure PastPresent
    Cold hands & feet PastPresent
    Bed-wetting PastPresent
    Frequent urination PastPresent
    Prostate trouble PastPresent
    Ringing in ears PastPresent
    Skin problems PastPresent
    Varicose veins PastPresent
    Eye problems PastPresent
    Throat problems PastPresent
    Thyroid problems PastPresent
    Menstrual problems PastPresent
    Fibrocystic diseasePastPresent
    Weight problem PastPresent
    Venereal disease PastPresent
    Alcoholism PastPresent
    Drug Abuse PastPresent

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

    Health IssueRelation to you
    Allergies
    Anxiety
    Asthma
    Back trouble
    Bowel trouble
    Cancer
    Depression
    Diabetes
    Epilepsy

    Health IssueRelation 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
    Energy12345678910
    Typical mood12345678910
    Digestion12345678910
    Job12345678910
    Physical home environment12345678910
    Physical work environment12345678910
    Parental relationships12345678910
    Friend relationships12345678910
    Romantic relationships12345678910
    Exercise12345678910
    Food12345678910
    Water12345678910
    Rest and Relaxation12345678910
    Spiritual life12345678910

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

    Do you take:Vitamins/MineralsHerbsHomeopathicsProbiotics

    Please indicate all of the following habits:

    Alcohol NoneModerateHeavy
    Coffee/Black tea NoneModerateHeavy
    Tobacco NoneModerateHeavy
    Marijuana NoneModerateHeavy
    Sugar NoneModerateHeavy
    Salt NoneModerateHeavy
    Coke/Pepsi/etc. NoneModerateHeavy
    Margarine/Crisco/etc. NoneModerateHeavy
    Cold cuts NoneModerateHeavy
    Fried Foods NoneModerateHeavy
    Barbecue NoneModerateHeavy
    Artificial Sweeteners NoneModerateHeavy
    Artificial colorings & flavorings NoneModerateHeavy

    Please describe your typical meals:

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

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