NEW CLIENT LONG INTAKE FORM - pearlphoenixhealth.com · Pearl Phoenix Health Copyright ©2015 page 2 Check next to illnesses that have occurred in any of your blood relatives: ____

Pearl Phoenix Health Copyright ©2015 page 1

RYLEN FEENEY, BA, LMT (#14733) Diplomate Chinese Herbs & Asian Bodywork Therapy Certified Amma Therapist Whole Foods Nutritionist Certified Instructor (AOBTA) 503.336.9730 [email protected] www.pearlphoenixhealth.com

NEW CLIENT LONG INTAKE FORM Name: __________________________________________________________ Date: ____________________

Address: __________________________________________________________________________________

City: _____________________________________ State: _____________ Zip: ____________________

Primary Phone:_____________________ Secondary Phone: ________________________

Email: _________________________________________

Age: ______________ Height: ___________Weight: ______________ D.O.B.: ________________

Occupation: _______________________________________________ Gender: ________________

Referred by: __________________________________ Committed Relationship? Y/N Children? Y/N and #______

Emergency contact: ___________________________ Phone: _______________________________________

MAJOR COMPLANT

What is your primary reason for this visit?:

___________________________________________________________________________________________

___________________________________________________________________________________________

Any medical conditions we should be aware of?

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

List any medications, herbs and/or supplements you are currently taking:

___________________________________________________________________________________________

___________________________________________________________________________________________

FAMILY HISTORY Father—Alive/Deceased. Present health or cause of death: ___________________________________________ Mother—Alive/Deceased. Present health or cause of death: __________________________________________ Brothers and/or Sisters—Number Alive ____ Number Deceased _____ Present health or cause of death: ______________________________________________________________ Children—Number Alive ______ Number Deceased _____ Present health or cause of death: ______________________________________________________________


Check next to illnesses that have occurred in any of your blood relatives: ____ Diabetes ____ Cancer ____ Bleeding Tendency ____ Kidney Disease ____ Tuberculosis ____ Obesity ____ Heart Disease ____ High Blood Pressure ____ Nerve Disorder ____ Allergy ____ Alcoholism ____ Mental Illness ____ Stroke ____ HIV/AIDs Other: ______________________________________________ PERSONAL MEDICAL HISTORY Describe your health as a child: _________________________________________________________________ ___________________________________________________________________________________________ Check next to illnesses or conditions you have or had in the past: ____ Diabetes ____ Glaucoma ____ Heart Trouble ____ High Blood Pressure ____ Thyroid Condition ____ Vein Trouble ____ Cancer ____ Asthma ____ Jaundice ____ STD ____ Bleeding Tendencies ____ Tuberculosis ____ Mumps ____ Pneumonia ____ Allergies ____ Kidney Disease ____ Rheumatic Fever ____ Nervous Disorder ____ Measles ____ Chicken Pox ____ HIV/Aids ____ Meningitis ____ Autoimmune Disorders ____ Mononucleosis ____ High Fevers ____ Lots of Antibiotic Use ____ Hepatitis ____ Polio ____ Gallbladder Trouble ____ Bladder Infections ____ Candidisis ____ Kidney Stones ____ Parasites Other: ________________________________________________________________________ List any surgeries: ___________________________________________________________________________ ___________________________________________________________________________________________ Any other serious injury, broken bones, traumatic events, scars, etc? ____________________________________ ___________________________________________________________________________________________ Are you pregnant? yes / no How many months? _______________________________ Have you had any recent (past year) immunizations? if yes what?: _____________________________________ Please list date of last physical: ____________________ Cholesterol test: ____________________ HIV Test: ___________________ Prostate Test: _______________________ Pap Smear: _________________ Mammography: ____________________ Blood tests (which?): _______________________________________________ Test Results: _________________________________________________________________________________ ___________________________________________________________________________________________ Are you currently receiving care from any of these? (check applicable) ___ Chiropractor ___ Acupuncturist ___ Medical ___ Dentist ___ Naturopath ___ Physical Therapist ___ Massage Therapist ___ Nutritionist COMMENTS (anything else you would like to tell us): ___________________________________________________________________________________________ ___________________________________________________________________________________________ CHECK ALL THAT APPLY CURRENTLY OR WITHIN THE PAST 6 MONTHS: GENERAL ___ fatigue ___ sleep problems ___ swollen glands ___ hot or cold intolerance ___ frequent headaches ___ weight loss / gain ___ fever or chills ___ allergies

___ nervousness ___ depressed ___ irritable NERVOUS SYSTEM ___ dizziness ___ blurred vision ___ fainting ___ paralysis

___ tremors ___ numbness/tingling ___ convulsions ___ imbalance ___ memory loss ___ muscle weakness


NECK ___ pain in neck ___ neck pain w/movement ___ pinched nerve in neck ___ neck feels out of place ___ stiff neck ___ muscle spasms in neck ___ popping sounds in neck ___ arthritis in neck ___ pain radiates ___ limited range of motion HEAD headache: note which area ___ entire head ___ back of head ___ forehead ___ temples ___ migraine ___ head feels heavy ___ loss of memory ___ light-headedness ___ fainting ___ light/sound/smell sensitivy ___ loss of smell ___ loss of taste ___ loss of balance ___ dizziness ___ loss of hearing ___ pain radiating into face ___ buzzing in ears ENT ___ ear ache ___ ear discharge ___ ringing in ears ___ hearing loss ___ loss of smell ___ mouth breather ___ snore when sleeping ___ nosebleeds ___ hoarseness ___ problems swallowing ___ swollen glands or throat ___ jaw tight or sore ___ dental problems ___ glasses/contacts EMOTIONAL ___ anxiety or worry ___ frequent crying ___ anger ___ chronic tension ___ mood swings ___ fear ___ restlessness ___ confusion ___ depression ___ suicidal

SKIN ___ easy bruising ___ dry skin ___ itching ___ boils ___ rashes ___ excessive sweat ___ hair changes BACK PAIN ___low back pain ___mid back pain ___Worse when ___ working ___ lifting ___ twisting ___ stooping ___ standing ___ sitting ___ lying ___ bending ___ coughing ___ pinched nerve ___ slipped disk ___ pain between shoulder blades ___ pain stabbing ___ rib feels out of place ___ pain radiates down leg ___ back feels out of place ___ muscle spasms ___ arthritis SHOULDERS ___ pain in shoulder joints ___ pain across shoulders ___ bursitis ( R / L) ___ arthritis (R / L) ___ can’t raise arm ___ tension in shoulders ___ pinched nerve in shoulder ___ muscle spasms in shoulders ARMS & HANDS ___ pain in upper arm (R / L) ___ pain in forearm (R / L) ___ pain in wrist (R / L) ___ pain in hands (R / L) ___ pain in fingers (R / L) ___ pins & needles in arms ___ pins & needles in hands ___ arms/hands/fingers go to sleep ___ hands cold ___ swollen joints in fingers ___ arthritis in fingers ___ loss of grip strength HIPS, LEGS & FEET ___ pain in buttock (R / L) ___ pain in hip joint (R / L) ___ pain down leg (R / L)

___ leg cramps ___ pins & needles in legs (R / L) ___ numbness in legs/feet (R / L) ___ feet feel cold ___ cramps in feet (R / L) ___ legs restless or jumpy ___ pain in knee (R / L) MUSCULOSKELETAL ___ joint inflammation ___ joint pain ___ muscle spasms ___ neck pain ___ shoulder pain ___ elbow pain ___ hand sensations ___ loss of grip ___ mid-back pain ___ rib pain ___ low back problems ___ hip pain ___ foot problems ___ leg cramps ___ knee pain ___ ankle weakness ___ tingling or numbness ___ stiffness ___ pain around ribs HEART/LUNG ___ chest pain ___ shortness of breath ___ chronic phlegm ___ high blood pressure ___ low blood pressure ___ persistent cough ___ hard to breathe ___ coughing blood ___ coughing phlegm ___ irregular heartbeat ___ varicose veins ___ ankle swelling GASTROINTESTINAL ___ change in appetite ___ thirst ___ nausea ___ vomiting ___ diarrhea ___ constipation ___ gas ___ hemorrhoids ___ gall bladder ___ belching ___ heartburn ___ abdominal pain ___ bloody/black stools ___ indigestion ___ liver trouble


GASTROINTESTINAL (continued) ___ psorosis ___ acne ___ eczema ___ swollen ankles/feet (R / L) ___ pain in feet (R / L) REPRODUCTIVE SYSTEM ___ painful intercourse ___ prostate problems

___ sexual problems ___ loss of sex drive ___ genital infections Birth control method ___________ WOMEN ONLY ___ painful periods ___ PMS ___ bloating ___ heavy periods ___ irregular periods

___ pregnant ___ fibroids ___ ovarian cysts date of last period ______________ # of pregnancies _______________ # of miscarriages ______________ # of abortions _________________ ___ difficult labor ___breast problems

NUTRITIONAL EVALUATION List some of your favorite foods or foods that you crave: _____________________________________________ ___________________________________________________________________________________________ List any known food sensitivities, allergies or foods that otherwise disagree with you: ___________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Are you currently on any kind of special diet or adhere to a particular food philosophy? Y / N Please explain: _______________________________________________________________________________ Do you frequently skip meals? Y / N If so which meal? _________________________________________ How many meals a day do you eat? __________ When is your biggest meal? ___________________________ DO YOU: eat fruits or vegetables at least twice a day? yes / no eat green or yellow vegetables at least twice a day? yes / no eat frequently between meals? yes / no eat frequently while stressed, worried or rushed? yes / no usually finish eating before others? yes / no chew your food thoroughly before swallowing it? yes / no drink juice, milk, or other drinks instead of water when thirsty? yes / no always add salt at the table? yes / no eat meat or dairy products 2 or more times a day? yes / no eat the same foods almost every day? yes / no eat when you’re not hungry? yes / no eat until you feel full? yes / no

frequently work while eating during your lunch break? yes / no have a history of dieting? yes / no frequently read or watch tv while eating? yes / no shop for bargin foods? yes / no do you currently or have you ever had an eating disorder? yes / no consume raw / cold / or iced foods or beverages daily? yes / no drink coffee? How much? ___________ What kind? ________________________ drink tea? How much? ______________ What kind? ________________________


Please take a moment to list what you have eaten in the last 24 hours: Breakfast: Lunch: Dinner: _____________________ ______________________ ________________________ _____________________ ______________________ ________________________ _____________________ ______________________ ________________________ _____________________ ______________________ ________________________ _____________________ ______________________ ________________________ Snacks: _____________________________________________________________________________ Check the types of foods you normally eat 3 or more times each week:___ artificially colored or sweetened drinks ___ soda pop diet / regular ___ coffee ___ fruit or vegetable juice ___ Milk ___ Milk substitutes: what kind _________________________ ___ desserts ___ white flour ___ food made with sugar ___ Water ___ lunch meats ___ poultry ___ canned fruits & veggies ___ frozen fruits & veggies ___ nuts ___ restaurant food ___ soy products ___ artificial sweeteners: which brand ____________________

___ fried foods ___ packaged foods (rice-a-roni, mac-n-cheese) ___ products w/wheat ___ Red meat (Beef, Lamb,Wild game etc) ___ Pork ___ Fish ___ 100% whole grain products ___ Shellfish ___ Sushi ___ sprouts ___ Eggs ___ Cheese ___ Yogurt ___ Salads ___ cooked vegetables ___ raw vegetables ___ fresh fruit ___ squash ___ dark leafy greens

Do you use: Alcohol? yes / no Amount per week: ________________ Type: _________________ Tobacco? yes / no Amount per week: ________________ Type: _________________ Recreational drugs/medications? yes / no Amount per week: _____________ Type: _______________ How many glasses of water do you drink a day? _____________________ (filtered / bottles) Do you react to any chemicals, cosmetics, household cleaners, smoke, fabrics, etc? ____________ If yes please list: _________________________________________________________________


Check any of the following items you are exposed to or use: ___ Aluminum cookware ___ Synthetic fibers ___ Teflon cookware ___ Heavy metals (lead, mercury, asbestos) ___ Microwave oven ___ Toxic chemicals ___ Computer terminal: ___ Electric blanket hours per day: _____ ___ Secondhand cigarette smoke ___ Fluorescent lights: ___ Periodic high noise levels hours per day: _____ ___ Air fresheners ___ Antiperspirants ___ Commercial shampoos and personal care products Do you live near: ___ A freeway or busy street ___ Airport ___ Major power line or electric substation ___ Nuclear reactor ___ Radio or TV transmission tower ___ Major industry: ___ Toxic waste site what kind? __________________ Do you like your neighborhood? ________________ LIFESTYLE EVALUATION Occupation: _______________________________________ Position held: ____________________________ How long? _______________________ What do you like most about your job? _________________________ __________________________________________________________________________________________ What do you like least about your job? ___________________________________________________________ Do you have financial worries? ______________ Highest level of education: ______________________ What are your hobbies/interests? ____________________________________________________________ How many hours per day do you watch TV? __________ Favorite show? ____________________________ What kind of stress do you have in your life? ______________________________________________________ On a scale from 1–10 (1 being none and 10 being the most extreme you can imagine), what is your current level of stress? ____________ Is your energy level: ___ high ___ low ___ up and down Do you exercise? ________________ If yes, how many hours a week? ________________ ___ outdoors ___ indoors What do you do for exercise?:_________________________________________ __________________________________________________________________________________________ How many hours do you sleep at night? _________________ Usual bedtime: ________________ Usual time you get up? _________________ Do you feel rested when you get up? ____________ How often do you take naps? _______________ How often do you wake up at night? _________ How long have you been with your spouse/significant other? ___________________ What is the most important health change you would like to occur? _________________________________ ______________________________________________________________________________________ How many hours do you spend alone? ______________ do you enjoy being alone? ___________ Do you have a spiritual or religious practice? yes / no Do you practice ___ prayer ___ meditation How often? ____________________________


PLEASE MARK YOUR AREAS OF CONCERN

Documents

NEW CLIENT LONG INTAKE FORM - pearlphoenixhealth.com · Pearl Phoenix Health Copyright ©2015 page 2 Check next to illnesses that have occurred in any of your blood relatives: ____