Patient Intake Form

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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____________________

____________________________________________________________________________

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.

____________________________________________________________

*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 ?

____________________________________________________________

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:

__________________________________________________________________________________________________________________________________________

(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:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

Please Expand on any concerns you have :

__________________________________________________________________________________________________________________________________________