Patient Intake and History Form
Please bring completed form to visit or:
Fax to: 812-282-283-2899 or
Mail to: Evergreen Medical Centre, Suite 3B - Jeffersonville, IN 47130
Name: _____________________________________________
Birthdate___________________________________________
Primary Insurance name and Identification Number: ___________________________________________________
Secondary Insurance Name and Number _______________________________________________________________
Contact Numbers:
Primary:_________________________________________Alternate_____________________________________
Address____________________________________________________________
_________________________________________________________________________
Emergency Contact Name and Number__________________________
EMAIL________________________________________________________________
Please sign the following questions (Email is never shared with anyone)
I wish to receive the Evergreen E-news online: Yes________________________ No_________________________
I give permission for the evergreen clinical staff to answer my medical questions on email:
Yes_____________________No________________________
I have a power of attorney or guardian: Yes No
Contact Number of power of attorney or guardian and Name
____________________________________________________________________________________________
How did you learn about our practice : Website __ Friend __ Referal __
What health problems would you like to address on your initial visit? Please rank by priority: Example: Headache - fatigue - back pain
1: ____________________________________________________________________________________________
2: ____________________________________________________________________________________________
3: ____________________________________________________________________________________________
4: ____________________________________________________________________________________________
5: ____________________________________________________________________________________________
6: ____________________________________________________________________________________________
Others: ________________________________________________________________________________________
What medical conditions have you been diagnosed with: (circle)
Hypertension Diabetes Type 2 Diabetes type 1 Cardiovascular disease Myocardial infarction
Stroke TIA Arrythmia Valvular disease_____________________ Carotid Artery Disease
Peripheral vascular disease Cancer: type________________________ Anemia Irritable Bowel
Chron;s or Colitis Diverticulitus Liver Diesease Pancreatitis Hypothyroidism Hyperthyroidism
Endocrine/gland disorder: type_________________________________________ Migraines
Depression Anxiety OCD Anorexia Other psychiatric issue_________________________
Seasonal allergies Food Aleergies Asthma COPD Excema/Psoriasis Osteoarthritis
Rheumatiod Arthritis Gout Psoriatic Arthritis Glaucoma Retinal Diseases Hearing Loss
Lupus Scleroderma Autoimmune disorder_________________________________________
Lyme Disease Bartonella Erlichosis Babesia List Other Diagnosis____________________
____________________________________________________________________________
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Smoking history: Yes __ No __
For how long________ Quit: Yes __ No __
Amount you smoke now:______________________________
Why:____________________________________________
Describe alcohol habits:_____________________________________
Describe any drug use or addictions____________________________
____________________________________________________________
Is there history of being abused or trauma: Yes No
Explain:_____________________________________________________
____________________________________________________________
List allergies to medicines or substances and reaction you get.
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
4. ______________________________________________
5. ______________________________________________
6. ______________________________________________
7. ______________________________________________
8. ______________________________________________
More:_________________________________________________________________
Please List all Prescription Medications and dosages:
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
4. ______________________________________________
5. ______________________________________________
6. ______________________________________________
7. ______________________________________________
8. ______________________________________________
9. ______________________________________________
10. _____________________________________________
Other/comments__________________________________
_______________________________________________
Please list all vitamins, supplements, herbs your taking now.
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
4. ______________________________________________
5. ______________________________________________
6. ______________________________________________
7. ______________________________________________
8. ______________________________________________
Comments/more:_____________________________________
__________________________________________________
FAMILY MEDICAL HISTORY
Who in your immediate family has any of the following? Place appropriate letter in blank and age (F=father, M=mother, S=sibling, G=grandparent)
____________Diabetes Type 1 or 2 __________Clotting Disorder
____________Alcoholism __________Depression/Anxiety
____________Heart Attack (age) __________Suicide
____________Heart Failure (age) __________Anemia
____________Stroke (age) __________Emphysema/COPD
____________Aneurysm __________Seizure Disorder
____________High Blood Pressure __________Skin disorders
____________High Cholesterol/Lipid __________Obesity
____________Glaucoma __________Cancer
____________Kidney Disease __________Cancer
____________Migraines/Headaches __________Osteoarthritis
____________Rheumatoid dz. __________Autoimmune Dz.
Other/Elaboration: _____________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Surgical History or Special Treatments (List surgeries and Dates):
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
4. ______________________________________________
5. ______________________________________________
6. ______________________________________________
7. ______________________________________________
Other:_______________________________________________________
Please briefly list biographical events you believe are relevant to your health. One suggestion is to consider 7 year phases in your life.
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*add seperate sheet if needed.
Are you: Single - Married - In a Relationship - Sexual Preference (optional):___________________________________________________
If in a relationship is it supportive ? Any relationship concerns ?
____________________________________________________________
____________________________________________________________
____________________________________________________________
What are the major stressors in your life ?
1.__________________________________________________________
2.__________________________________________________________
3.__________________________________________________________
4.__________________________________________________________
Others:
What do you do to relax/relieve stress? What interests/hobbies do you have?
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Spiritual/Religous Beliefs or Practices. How do you practice i.e. prayer,meditation, relaxation exercises etc.
________________________________________________________
________________________________________________________
________________________________________________________
How often do you practice: (circle) Rarely Weekly Daily
Current and Past Occupations or Disability: ______________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Do you exercise ? How long and how often ? What do you do ?
____________________________________________________________
____________________________________________________________
If no exercise why ?_______________________________________
Energy level: Very Good - Average - Poor Does sleep help ? Yes __ No __
Describe your sleep habits: ____________________________________
____________________________________________________________
____________________________________________________________
Nutrition:
How many meals do you generally eat per day? ______
Do you skip meals? Yes__ No __
How many servings of fruit per day?______
How many servings of vegetables a day (not white potatoes/corn/peas) ______.
Do you eat a lot of - canned - frozen - fresh food? _____________________
Do you eat raw foods or juice ? ___________________________________
Are you currently on a special diet and is it working well ? ______________
____________________________________________________________
____________________________________________________________
Do you eat organic or local foods as a general habit ? Yes__ No __
What meat or protein do consume ?_______________________________
____________________________________________________________
Are your animal products mostly free range or grass fed ? Yes __ No __
Where do get your food mostly? __________________________________
What do you snack on mostly? ___________________________________
How much and what do you drink? ________________________________
____________________________________________________________
How often do you eat out and where: _______________________________
____________________________________________________________
How much sugar, caffeine or diet sweeteners do you consume daily ?
____________________________________________________________
____________________________________________________________
How would you describe your goals concerning your nutrition ? Do you have specific questions ? Particular concerns ?
____________________________________________________________
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Optional: If you any question, concerns or challenges related to hormones or sexual activity please explain. If it applies please list any history of birth control, surgeries, abortions(optional), failed pregnancies, fertility, number of children, menstrual or menopausal challenges and etc:
__________________________________________________________________________________________________________________________________________
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(Optional): Please describe your history of joint or musculoskeletal injuries/problems if interested in Prolotherapy, PRP, Fat cell Matrix Grafting, Osteopathic, Craniosacral or other musculoskeletal treatments. Also listany specific questions you have:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Please Expand on any concerns you have :
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