Patient Intake Form | Vibrant Life Oklahoma

Last Name*

First Name*

Date of Birth

Address*

Street Address City State ZIP Code

Phone Number*

Email Address*

Marital Status*

Sex*

Are you currently being treated in this office?*

Yes
No

For what?*

By whom?*

How did you hear about us?*

Past Medical & Surgical History:

Please indicate when you have had these conditions and the treatments provided in the field below

Conditions*

Please indicate when you have had the above conditions and the treatments provided*

Social History

Do you currently smoke?*

Yes
No

Have you ever smoked?*

Yes
No

If yes, for how long and how many packs per day?

Are you exposed to second-hand smoke?*

Yes
No

Do you consume alcohol?*

Yes
No

How often?*

How many drinks per sitting?*

Family History

Please indicate who had these conditions

Medications and Supplements

What medications are you taking now? Include non-prescription drugs. List medication name, date started, and dosage.*

Are you allergic to any medications?*

Yes
No

If yes, please list medication and reaction:

List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible. Vitamin/Mineral/Supplement name, Date started, Dosage*

Dietary Considerations

As a child, were there any foods that you had to avoid because they gave you symptoms?*

Yes
No

If yes, please: name the food and symptom (Example: milk – gas and diarrhea)

How much/How often do you consume the following each week? (Never, 1-3 times, 3-7 times, more than 7 times)

Candy*

Never
1-3 times
3-7 times
more than 7 times

Cheese, Milk, Ice cream and other dairy products*

Never
1-3 times
3-7 times
more than 7 times

Chocolate*

Never
1-3 times
3-7 times
more than 7 times

Cups of coffee containing caffeine*

Never
1-3 times
3-7 times
more than 7 times

Cups of decaf coffee or tea*

Never
1-3 times
3-7 times
more than 7 times

Cups of tea containing caffeine*

Never
1-3 times
3-7 times
more than 7 times

Diet soda*

Never
1-3 times
3-7 times
more than 7 times

Regular soda*

Never
1-3 times
3-7 times
more than 7 times

Salty foods*

Never
1-3 times
3-7 times
more than 7 times

White bread products (rolls/bagels/pasta)*

Never
1-3 times
3-7 times
more than 7 times

Sodas with caffeine*

Never
1-3 times
3-7 times
more than 7 times

odas without caffeine*

Never
1-3 times
3-7 times
more than 7 times

Are you on a special diet?*

Yes
No

If yes, please explain:

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?*

Yes
No

If yes, are these symptoms associated with any particular food or supplement(s)?*

Yes
No

Please name the food or supplement and symptom(s). Example: Milk – gas and diarrhea.

Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.?*

Yes
No

Do you feel worse when you eat a lot of (check all that apply):

Please explain

Do you feel better when you eat a lot of (check all that apply):

Does skipping a meal greatly affect your symptoms?*

Yes
No

Have you ever had a food that you craved or really "binged" on over a period of time? Food craving may be an indicator that you may be allergic to that food.*

Yes
No

If yes, what food(s)?

Do you have an aversion to certain foods?*

Yes
No

If yes, what food(s)?

Do you exercise regularly?*

Yes
No

If so, how many times a week

What type of exercise is it?

Women Only

Have you ever been pregnant?

Yes
No

Number of miscarriages

Number of abortions

Number of preemies

Number of term births

Birth weight of largest baby

Smallest baby

Did you develop toxemia (high blood pressure)?

Yes
No

Have you had other problems with pregnancy?

Yes
No

If so, please comment:

Age at first period

Date of last Pap Smear

Date of last Mammogram

Pap Smear

Normal
Abnormal

Mammogram

Normal
Abnormal

Have you ever used birth control pills?

Yes
No

If yes, when

Are you taking birth control pills now?

Yes
No

Are you in menopause?

Yes
No

If yes, age at last period

How long have you been on hormone replacement therapy (if applicable)?

In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)?

Yes
No
Not Applicable

Recent Symptoms

Please circle if these symptoms occur presently or have occurred in the past 6 months.

GENERAL:

HEAD, EYES & EARS:

MUSCULOSKELETAL:

MOOD/NERVES:

EATING:

DIGESTION:

SKIN PROBLEMS:

SKIN, ITCHING:

LYMPH NODES:

RESPIRATORY:

CARDIOVASCULAR:

URINARY:

MALE REPRODUCTIVE:

FEMALE REPRODUCTIVE:

Goals

What goals would you like to achieve being treated in this office?*

What, if any, limitations do you have with working with the doctors in our office toward achieving these goals?

On a scale of 1-10, with 10 being the highest, how is your energy level today?*

On a scale of 1-10, with 10 being the highest, how is your pain level today?*

On a scale of 1-10, with 10 being the highest, how is your mood today?*

What is your biggest concern today?*

Other Comments

Insurance Information

Name of Insurance*

ID Number*

Group Number*

Person Insured*

Insured Date of Birth*