Health Intake Questionnaire

Jane Brown

First Name Last Name

Marital Status

Single Married Divorced Separated Widowed

7638 Dogwood Dr

Address

Waimanalo HI 96795

City State Zip

7198576752 02/25/1951

Phone DOB

Matthew Brown (314) 869-6670

Spouse Name Spouse Phone

Is the requested medication NEW or a CONTINUATION of THERAPY? If so, start date: ____________________

Have you been hospitalized in the past year? Yes No

Previous Health History

Dr. David Anderson 09-12-1951

Primary Care Physician Last Seen Date

Have you received chiropractic care? Yes No

Have you received acupuncture care? Yes No

Prescription Drugs:

Antidepressants	Anti Inflammatory
Birth Control Pills	Blood Pressure Medication
Diet Pills	Blood Sugar Medication
Muscle Relaxers	Insulin
Pain Pills	Sleeping Pills
Other: fluticasone

allegra

Over-the-Counter Drugs

Accidents or Injuries

alpha-lipoic acid, vitamin b7, glucosamine, flaxseed oil

Vitamins or Supplements

Review of Symptoms

Allergies	Black Outs
Blurred Vision	Calf Pain
Chest Pain	Chills
Coughing	Coughing Up Blood
Dental Problems	Difficulty Emptying Bowel Or Bladder
Double Vision	Enlarged Glands
Excessive Bruising	Excessive Stress
Excessive Thirst	Eye Pain
Fatigue	Fever
Headaches	Hearing Loss
Irregular Heart Rate	Joint Swelling
Muscle Pain	Seizures
Shortness Of Breath	Stomach Trouble Or Ulcers
Tuberculosis Exposure	Weight Gain Or Loss Greater Than 10 Lbs