Functional Medicine Patient Intake

We are excited you have chosen us to assist you with your condition. Please fill out the information below as completely

as possible so the Doctor(s) may properly evaluate you. If you need assistance, please ask the front desk!

Confidential Patient Information PLEASE PRINT LEGIBLY

Legal Name_____________________________________________________________________________________

Address_______________________________________City ________________________State_______ Zip________

Cell Phone ________________________________ Email _________________________________________________

Birth Date_____________________ Age_______ Male Female Social Security #________________________

Occupation________________________________________ Employer ______________________________________

Marital Status: Married Divorced Single Widowed

Emergency Contact ___________________________________ Phone # _____________________________________

What Brought You to Our Clinic?

- Patient Name: ____________________ r? Name: _______________

– Channel? _______________ – Station?______________________

Were you satisfied with your care? YES

Current Health

Are you receiving care from other health professionals? YES

If yes, please name them and their speciality_____________________________________________________________

Please list any drugs or medications you are taking, including any vitamins or herbs_______________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Do you use: Coffee Tea Artificial Sweeteners Sugar Alcohol Cigarettes Recreational Drugs

Are you pregnant? YES

What are your most pressing health concerns?____________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

For how long?______________________________________________________________________________________

Is it: Getting Worse Improving Intermittent Constant Unsure

Current Symptom Levels:

How would you rate your symptoms on average in the last month?

NONE 1 2 3 4 5 6 7 8 9 10 WORST POSSIBLE

If you had to accept some level of symptoms after completion of treatment, what would be an acceptable level?

NONE 1 2 3 4 5 6 7 8 9 10 WORST POSSIBLE

Have you ever suffered from: (please check all that apply)

Dizziness Irritability Neck Pain Buzzing/Ringing in Ear Fatigue

Memory Loss Chest Pain Back Pain Jaw Problems Paralysis

Tension Neck Stiffness Leg Pain Loss of Sleep Blurred Vision

Upset Stomach Nausea Arm/Shoulder Pain Shortness of Breath Depression

Back Stiffness Numbness Allergies Headache/Migraine Fainting

Arm Tingling Constipation Vomiting Abnormal Blood Pressure Vomiting

Back Tingling Liver Problems Leg Pain/Tingling Irregular Heartbeat Ear Pain

Hand Pain/Tingling Hemorrhoids Lung Problems Painful Urination Colitis

Weight Loss Heart Problems Heartburn

Patient History

Condition Past Present Condition Past Present Condition Past Present

Angina/Chest Pain Headaches Night Sweats

Arthritis Heart Problems Numbness

Asthma HIV Paralysis

Balance Problems Irritability Seizures

Broken Bones Joint Stiffness Sleeping Problems

Cancer Joint Swelling Scoliosis

Chills Joint Tenderness Stiffness

Concentration Loss Loss of Sleep Stroke / TIA

Diabetes Lumps Tingling

Dizziness Masses Thyroid Problems

Fatigue Memory Loss Tremors

Fainting Muscle Cramps Vertigo

Fever Muscle Pain Weakness

Gout Nervousness Other Please List:

Informed Consent and HIPAA / Privacy Practices

INFORMED CONSENT I hereby request and consent to the performance of: physical examinations and evaluations and performance of

any tests required to be performed to diagnose my condition(s), and for treatment, including various modes of physical and rehabilitation

therapy, which the doctor will explain to me, and of other procedures on me by or under the supervision of the doctor named below, or

by trained clinic staff, or other licensed doctors who now or in the future treat me while employed by, working, or associated with, or

serving as back-up for the doctor named below, including those working at the clinic or office listed below or any other office or clinic.

I have had, or will when questions arise, take the opportunity to discuss with the doctor named below and/or with other office or clinic

personnel, the nature and purpose of all procedures. I understand that results cannot be guaranteed. I understand and am informed that,

as in any healthcare practice, there are some rare risks to treatment, including, but not limited to: no results, fractures, disc or spine

injuries, strokes, dislocations and sprains.

I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise

judgment during the treatments which the doctor recommends at the time, based upon the facts then known, and is in my best interests.

I have read, or had read to me, the above consent. I have also had an opportunity, or will take the opportunity, to ask questions about its

content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment

for my present conditions(s) and for any future condition(s) for which I seek treatment.

HIPAA. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about

you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by requesting at the front desk.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or

health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

By my signature below, I acknowledge I have had the opportunity to review the Notice of Privacy Practices located at the front desk.

______ Release of Medical Records for My Medical care or as required By Law:

-To health care providers involved in my care

-To State, Federal, and accrediting bodies for required reporting data and/or surveys for compliance

-For purposes of my care and for business operations

______ Assignment of Benefits/Bill My Insurance

-I authorize Select Health of the Twin Cities to send my bills for my medical care and treatment to my insurance

company and/or Medicare or Medicaid for payment. To the extent that my insurance company and or/Medicare/Medicaid is

required to pay the bill under terms of my insurance policy or by law.

-I request that my insurance company and or/Medicare or Medicaid pay Select Health of the Twin Cities and the

providers who are involved in my treatment.

-I consent to the release of my medical records by Select Health of the Twin Cities to my insurance company

and/or Medicare or Medicaid (and organizations working on their behalf) if necessary in order for my bills to be paid.

-I agree to pay for charges not covered by insurance.

-I understand that if I do not check this box, Select Health of the Twin Cities will bill me directly to collect

payment for services rendered.

Please Complete

Patient’s Name________________________Signature___________________________________ Date______________

Name_________________________________________Relationship_________________________________________

(Above named has permission to receive information regarding my records)

_________________________________/__________ ___________________________/_________

If applicable - Translated by Witness to Patient’s Signature Date

Print name(s) of primary doctor(s) treating this patient:

Dr. Jamy Antoine, D.C, Dr. Don Jewell, D.C and/or Dr. Daniel Piper, D.C

Name: ___________________________________________ Age: ______ Sex: _____ Date: ______________ PART I Please list your 5 major health concerns in order of importance:1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________3. __________________________________________________________________________________________4. __________________________________________________________________________________________5. __________________________________________________________________________________________

PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Metabolic Assessment Form

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

Category I Feelingthatbowelsdonotemptycompletely LowerabdominalpainrelievedbypassingstoolorgasAlternatingconstipationanddiarrhea DiarrheaConstipationHard,dry,orsmallstoolCoatedtongueor“fuzzy”debrisontonguePasslargeamountoffoul-smellinggasMorethan3bowelmovementsdailyUselaxativesfrequently

Category II IncreasingfrequencyoffoodreactionsUnpredictablefoodreactionsAches,pains,andswellingthroughoutthebodyUnpredictableabdominalswellingFrequentbloatinganddistentionaftereating Abdominalintolerancetosugarsandstarches Category III IntolerancetosmellsIntolerancetojewelryIntolerancetoshampoo,lotion,detergents,etc.MultiplesmellandchemicalsensitivitiesConstantskinoutbreaks Category IV Excessivebelching,burping,orbloatingGasimmediatelyfollowingamealOffensivebreathDifficultbowelmovementSenseoffullnessduringandaftermealsDifficultydigestingfruitsandvegetables; undigestedfoodfoundinstools

Category VStomachpain,burning,oraching1-4hoursaftereatingUseantacidsFeelhungryanhourortwoaftereatingHeartburnwhenlyingdownorbendingforwardTemporaryreliefbyusingantacids,food,milk,or carbonatedbeveragesDigestiveproblemssubsidewithrestandrelaxationHeartburnduetospicyfoods,chocolate,citrus, peppers,alcohol,andcaffeine

Category VI RoughageandfibercauseconstipationIndigestionandfullnesslast2-4hoursaftereatingPain,tenderness,sorenessonleftsideunderribcageExcessivepassageofgas

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

Category VI (continued)Nauseaand/orvomitingStoolundigested,foulsmelling,mucouslike, greasy,orpoorlyformedFrequenturinationIncreasedthirstandappetite

Category VII Greasyorhigh-fatfoodscausedistressLowerbowelgasand/orbloatingseveralhours aftereatingBittermetallictasteinmouth,especiallyinthemorningBurpy,fishytasteafterconsumingfishoilsDifficultylosingweightUnexplaineditchyskinYellowishcasttoeyesStoolcoloralternatesfromclaycoloredto normalbrownReddenedskin,especiallypalmsDryorflakyskinand/orhairHistoryofgallbladderattacksorstonesHaveyouhadyourgallbladderremoved?

Category VIIIAcneandunhealthyskinExcessivehairlossOverallsenseofbloatingBodilyswellingfornoreasonHormoneimbalancesWeightgainPoorbowelfunctionExcessivelyfoul-smellingsweat

Category IX CravesweetsduringthedayIrritableifmealsaremissedDependoncoffeetokeepgoing/getstartedGetlight-headedifmealsaremissedEatingrelievesfatigueFeelshaky,jittery,orhavetremorsAgitated,easilyupset,nervousPoormemory/forgetfulBlurredvision

Category XFatigueaftermealsCravesweetsduringthedayEatingsweetsdoesnotrelievecravingsforsugarMusthavesweetsaftermealsWaistgirthisequalorlargerthanhipgirthFrequenturinationIncreasedthirstandappetiteDifficultylosingweight

0 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)

PART IIIHowmanyalcoholicbeveragesdoyouconsumeperweek?Howmanycaffeinatedbeveragesdoyouconsumeperday?Howmanytimesdoyoueatoutperweek?Howmanytimesdoyoueatrawnutsorseedsperweek?Listthethreeworstfoodsyoueatduringtheaverageweek:Listthethreehealthiestfoodsyoueatduringtheaverageweek:PART IVPlease list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Category XI CannotstayasleepCravesaltSlowstarterinthemorningAfternoonfatigueDizzinesswhenstandingupquicklyAfternoonheadachesHeadacheswithexertionorstressWeaknails

Category XIICannotfallasleepPerspireeasilyUnderhighamountofstressWeightgainwhenunderstressWakeuptiredevenafter6ormorehoursofsleepExcessiveperspirationorperspirationwithlittle ornoactivity

Category XIII EdemaandswellinginanklesandwristsMusclecrampingPoormuscleenduranceFrequenturinationFrequentthirstCravesaltAbnormalsweatingfromminimalactivityAlterationinbowelregularityInabilitytoholdbreathforlongperiodsShallow,rapidbreathing

Category XIVTired/sluggishFeelcold―hands,feet,alloverRequireexcessiveamountsofsleeptofunctionproperlyIncreaseinweightevenwithlow-caloriedietGainweighteasilyDifficult,infrequentbowelmovementsDepression/lackofmotivationMorningheadachesthatwearoffasthedayprogressesOuterthirdofeyebrowthinsThinningofhaironscalp,face,orgenitals,orexcessive hairlossDrynessofskinand/orscalpMentalsluggishness

Category XVHeartpalpitationsInwardtremblingIncreasedpulseevenatrestNervousandemotionalInsomniaNightsweatsDifficultygainingweight

Category XVIDiminishedsexdriveMenstrualdisordersorlackofmenstruationIncreasedabilitytoeatsugarswithoutsymptoms

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

Category XVII IncreasedsexdriveTolerancetosugarsreduced“Splitting”-typeheadaches

Category XVIII (Males Only)UrinationdifficultyordribblingFrequenturinationPaininsideoflegsorheelsFeelingofincompletebowelemptyingLegtwitchingatnight

Category XIX (Males Only)DecreasedlibidoDecreasednumberofspontaneousmorningerectionsDecreasedfullnessoferectionsDifficultymaintainingmorningerectionsSpellsofmentalfatigueInabilitytoconcentrateEpisodesofdepressionMusclesorenessDecreasedphysicalstaminaUnexplainedweightgainIncreaseinfatdistributionaroundchestandhipsSweatingattacksMoreemotionalthaninthepast

Category XX (Menstruating Females Only)PerimenopausalAlternatingmenstrualcyclelengthsExtendedmenstrualcycle(greaterthan32days)Shortenedmenstrualcycle(lessthan24days)PainandcrampingduringperiodsScantybloodflowHeavybloodflowBreastpainandswellingduringmensesPelvicpainduringmensesIrritableanddepressedduringmensesAcneFacialhairgrowthHairloss/thinning

Category XXI (Menopausal Females Only)Howmanyyearshaveyoubeenmenopausal?Sincemenopause,doyoueverhaveuterinebleeding?HotflashesMentalfogginessDisinterestinsexMoodswingsDepressionPainfulintercourseShrinkingbreastsFacialhairgrowthAcneIncreasedvaginalpain,dryness,oritching

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)

Rateyourstresslevelonascaleof1-10duringtheaverageweek:Howmanytimesdoyoueatfishperweek?Howmanytimesdoyouworkoutperweek?