Intake Form - Chance To Change

Client Intake Form

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Personal Information

First Name (required)	MI	Last Name (required)
Date of Birth (required)	Social Security Number (required)
Email (required)		Phone (required)
Previous or Referring Doctor
Date of Last Physical Exam
Sex Assigned at Birth	Gender Identity
Which of the following best describes you?

Insurance Information

Insurance Provider
Member ID / Policy #	Policyholder Name (if different)
Relationship to Client

Emergency Contact Information

Emergency Contact - First Name (required)	Emergency Contact - MI	Emergency Contact - Last Name (required)
Relationship to Patient (required)
Primary Number (required)	Email (required)

Medical & Mental Health History

Medical History — select all that apply

Alcohol/Drug ProblemAnemiaAnxietyArthritisBlood ClotsChest PainConnective Tissue DiseaseCancerDementiaDiabetesDepressionEmphysema/COPDEating DisorderHeart AttackHeart FailureHigh Blood PressureHigh CholesterolHypothyroidism (low)Hyperthyroidism (high)Irritable Bowel Syndrome (IBS)Kidney DiseaseLiver DiseaseLung DiseaseMigrainesOsteoporosisProstate issuePsychiatric DisorderSeizures or strokesSleep ApneaWeight Gain/Loss

Please select all that apply to you

I have previously received or am currently receiving medical treatment.I have previously had a surgery.I have previously been admitted to a hospital.I currently take medications.I have an allergy to a food or medication.I currently take vitamins or supplements.

Vaccinations

Tetanus YesNo	Influenza (Flu) YesNo
Hepatitis B YesNo	Pneumonia/Pneumovax YesNo
Hepatitis A YesNo	Gardasil (HPV) YesNo
Prevnar 13 YesNo	Shingles/Zostavax YesNo

Mental Health & Psychiatric History — check all that apply

I have been diagnosed with a mental health or psychiatric disorder.I have attempted suicide.I have engaged in self harm behavior.

Please list any outpatient mental health treatment received

Family & Social History

Family Health History (medical and mental health, immediate family)

Current Amount of Exercise
Do you smoke cigarettes? YesNeverQuit	Do you vape (e-cigarettes)? YesNo
Other Tobacco Use? Chewing TobaccoPipeCigars
Do you drink alcohol? YesNo	Do you use recreational drugs?
Are you sexually active?
Contraception NoneCondomPill/Ring/IUD/Patch/InjVasectomy	History of Sexually Transmitted Infection (STIs)? YesNo
Employment Status	Highest Level of Education
Marital Status	Number of Children

Review of Systems

General

Fever or ChillsTrouble sleepingWeaknessUnexplained tiredness or fatigueUnexpected weight change

Cardiovascular

Chest painHeart poundingIrregular heartbeatLeg pain when walkingDecreased exercise tolerance

Skin

RashNew/changing skin lesionNew/changing molesHair lossNail changes

Eyes

PainRednessVision loss/changeDischargeDry or itchy eyesBlurred visionGlasses or contacts

Musculoskeletal

Joint painJoint swellingJoint stiffnessMuscle painMuscle weaknessNeck pain

Respiratory

CoughShortness of breathWheezingDifficulty breathingNight sweatsSnoring

Neurological

HeadachesDizziness or light-headednessNumbnessSeizuresSpeech difficultyTremors

Endocrine

Change in appetiteCold or heat intoleranceIncreased thirstChanges in sex driveHair loss or excess hair growth

Hematologic

Bruises easilyBleeds easilyProlonged bleedingEnlarged lymph nodes

Gastrointestinal

Abdominal painBlood in stoolConstipationDiarrheaNauseaVomitingHeartburn

Genitourinary

Painful urinationAbnormal/frequent urinationBlood in urineLoss of bladder controlDifficulty urinatingGenital sores

Men

Difficulty starting stream/weak streamChange in urine streamPenile dischargeTesticular pain or massErection difficulties

Ear, Nose, Mouth & Throat

EaracheHearing LossNosebleedsRunny noseSinus painSore throatHoarsenessDry Mouth

Psychiatric

Thoughts of harm to self or othersSleep problemsAnxietyDepressionChange in personalityEmotional problemsAgitationSelf-injury or suicidal thoughts

Women

Pelvic painIrregular periodsUnusual vaginal dischargeExcessive vaginal bleedingHot flashesPain with intercourseBleeding after menopauseBreast painBreast lump/massNipple discharge

Other symptoms not mentioned

Acknowledgements & Consent

By signing your name below, you acknowledge that you are the individual who completed all information within this form.

Date (required)	Print Name - First (required)	Print Name - Last (required)
Relationship to Patient (required)

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