Patient Intake First Name(Required) First Last Name(Required) Preferred Name First Last Cell Phone(Required)Home PhoneWork PhoneAddress(Required) Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Age(Required)Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insurance Company Insurance ID#: Height (Feet)Height (inches) Weight lbsGender assigned at birth(Required)MaleFemaleOtherMarital Status(Required)SingleMarriedPartneredDivorcedWidowedSeparatedPronoun(Required)He/himShe/herThey/themEmployer: Occupation:(Required) Emergency Contact:(Required) PhoneRelationship How did you hear about us or who may we thank for referring you?(Required) Name of your primary care physician? PhonePlease list other practitioners that you have seen for your health concerns:NamePhone Add RemovePlease list any prescriptions, supplements, or over the counter medications you are currently taking:Medication or SupplementFor?DosageMedication or SupplementFor?Dosage Add RemoveWhat is your primary health concern?(Required) When did this problem begin?(Required) What makes it better or worse?(Required) Has this condition been evaluated by another physician?(Required) If so, list any known diagnosis: What prior treatments have you had for this condition and what were the results? Does this impair your daily activities?(Required) If so, how? Please list any other health concerns that you wish to address: Add RemovePlease provide complete information in the following pages related to your current and past health concerns.HiddenPlease upload your current and past health concernsMax. file size: 1 MB.AllergiesPastPresentAsthmaPastPresentBlood PressurePastPresentBruise EasilyPastPresentCancerPastPresentChicken PoxPastPresentDiabetesPastPresentEmphysemaPastPresentEpilepsyPastPresentGlaucomaPastPresentHeart DiseasePastPresentHepatitisPastPresentHerpes VirusPastPresentHigh FeverPastPresentHIVPastPresentJaundicePastPresentLyme DiseasePastPresentMeaslesPastPresentMeningitisPastPresentMononucleosisPastPresentMultiple SclerosisPastPresentPneumoniaPastPresentRheumatic FeverPastPresentSTI'sPastPresentThyroid DisorderPastPresentTuberculosisPastPresentOther:PastPresentPlease provide complete information in the following pages related to your Recent Medical Tests:HiddenPlease upload your recent medical testsMax. file size: 1 MB.CBC / FerritinDateResultsComplete Metabolic / Blood Sugar:DateResultsThyroid: TSH, Free T4, Free T3DateResultsCholesterol TC, HDL, LDL, TGDateResultsVitamin DDateResultsCancer MarkersDateResultsHormones (Prog, Est, Test)DateResultsAdrenal (cortisol, DHEA)DateResultsProstate PSADateResultsGI TestingDateResultsMammogramDateResultsPhysicalDateResultsPap SmearDateResultsSTI testingDateResultsUltrasoundsDateResultsPathology reportsDateResultsOther testing / ImagingDateResultsList any prior surgeries and what they were for and the date or approximate date / year performedTypeReasonDate Add RemoveFAMILY HISTORYPlease indicate family history of:(Required) Cancer Heart Disease Thyroid Diabetes Endocrine Infertility Allergies Auto-immune Disease High Blood Pressure High Cholesterol Other None Please indicate any personal addictions to(Required) Nicotine Prescription Medications Alcohol Other None Describe other family history Describe other personal addictions HEALTH CONCERNSEnergy, Emotions, and Immunity(Required) Fatigue Chronic Fatigue Mood Swings Anxious / Nervous Mental Tension Panic Attacks Overwhelmed Overworked Anger /Irritable Grief Depression Suicidal Thoughts Joy Cold Hands/Feet Slow Wound Healing Easy to Catch Colds None Stress Level ____/1012345678910Number of hours of sleep per night:123456789101112Sleep(Required) Restless Busy Mind Night Sweats Nightmares Difficult to fall asleep Difficult to stay asleep Vivid Dreaming Awake to urinate Awaken with pain None Cardiovascular:(Required) Heart Disease Chest Pain Swelling of Ankles Heart Murmurs High Blood Pressure Palpitations / Fluttering Poor Circulation Varicose Veins None Respiratory:(Required) Cough Shortness of Breath Pneumonia Pleurisy Tobacco Use Current Tobacco Use Past Asthma None Skin(Required) Rash Eczema Psoriasis Itchy Skin Dry Skin Hives Acne Dandruff None Head, Eye, Ear, Nose, Throat:(Required) Impaired Vision Eye Pain / Strain Glaucoma Tearing / Dryness Impaired Hearing Ear Ringing Earaches Swollen Glands Headaches Migraines Allergies Frequent Sore Throats Sinus Problems Nasal Discharge Nose Bleeds Teeth Grinding / TMJ Sores on tip of tongue Gum Disease Teeth Problems Dry Mouth None Gastrointestinal:(Required) Nausea / Vomiting Heartburn Belching / Gas Blood in Stool Gurgling in Stomach Undigested Food in Stool Fatigue after Eating Mucous in Stool Ulcers Incomplete Stools Bloating Abdominal Pain Diarrhea Constipation Gallbladder Disease Liver Disease Hemorrhoids Hernia Food Cravings None Female Reproductive:(Required) Irregular Cycles Amenorrhea (no periods) Painful Periods PMS Light Flow Heavy Flow Clotting Bleeding Between Cycles Vaginal Itching Vaginal Discharge Sores on Genitalia Vaginal /Vulvar Pain Pain w/ Sex Menopausal Symptoms Nipple Discharge Breast Lumps / Tenderness Pregnancies Miscarriages Live Births Birth Complications: Other None Genito-Urinary Tract(Required) Painful Urination Frequent Urination Blood in Urine Frequent Urination at Night Frequent UTI Kidney Stones Kidney Disease Incontinence Urgent Urination Painful Intercourse Sexually Transmitted Infection None Musculoskeletal:(Required) Low Back Pain Neck / Shoulder Pain Mid Back Pain Arm Pain Leg Pain Muscle Spasms / Cramps Arthritis Tendonitis Other Pain None Endocrine:(Required) Hypothyroid Hypoglycemia Diabetes Mellitus Feel Hot Feel Cold Low Libido Hair Loss None Neurological:(Required) Vertigo / Dizziness Numbness / Tingling Loss of Balance Paralysis None Please describe other pain Please describe other Female Reproductive Are you currently pregnant?YesNoPlease list due date: MM slash DD slash YYYY Are you currently taking hormonal birth control?YesNoPlease list medication: Are you interested in learning more about the various pelvic floor rehabilitation therapies that we offer (trigger point therapy, Holistic Pelvic Care ™, and THERMIva, MLT)?Yes, please tell me moreNot at this time*If you are seeing us for preconception counseling or infertility concerns, please make sure you fill out our separate https://www.amberwellnessgroup.com/womens-fertility-history-form/. (If you click on the questionnaire link, you will need to return to this page to complete this intake as well.)Male Reproductive: Prostate Problems Testicular Pain / Swelling Sexual Difficulties Penile Discharge None Habits / Lifestyle:Exercise: times/week(Required) Excercise(Required) Mild Moderate Intense None Hobbies:(Required) WorkLight LaborHeavy LaborWork Activity(Required) Sitting Standing Computer Work hours/week(Required) Do you enjoy your work?(Required)YesNoAlcohol:(Required)YesNoAlcohol days/ week? Caffeine(Required)YesNoWater: Cups/day:(Required) Stress Level:(Required)MildMediumHighNoneTobacco(Required)YesNoSpiritual Practice(Required)YesNoTelevision(Required)YesNoReading(Required)YesNoHave you experienced any major traumas?(Required)YesNoPlease Explain:Typical Daily Food Menu:(Required)Breakfast:Lunch:Dinner:Snacks:Beverages: Add RemoveList any food allergies, sensitivities, or intolerances and your reaction:(Required)List any allergies related to medications or supplements and your reaction:(Required)By signing below: I acknowledge that I have been provided ample opportunity to read the HIPAA Notice of Privacy Practices provided by the clinic or that it has been read to me. I understand all of the above and give my oral and written consent to evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment. I agree that I will consult the consent form or call the office for clarification when I have concerns regarding my care at Amber Wellness Group. Printed Name of Patient/Guardian(Required) First Name Last Name Signature of Patient/ Parent/ Guardian(Required)Date(Required) MM slash DD slash YYYY
