New Client Intake

Contact Information

Name Date Phone Email

Address

Emergency Contact Name Emergency Contact Phone

How did you hear about us?

Past Medical History

Please check any that apply

Other medical history, dates, and details Past surgery, including approximate date and procedure Allergies

General Health

Excellent Good Fair Poor

Reason for visit If you could change three things about yourself and your life, what would they be?

Family History

Mother name(s) / age / status Father name(s) / age / status Brother(s) name(s) / age / status Sister(s) name(s) / age / status

Condition	Yes	No	Unsure	Who

Other family history

Social History

Where were you born? Where did you grow up?

Current marital status

Single Married Divorced Other

If not, have you ever been married or in a committed relationship?

Do you have children?

Yes No

Education completed

Grade school High school Trade school College

Occupation

Employed Unemployed Retired

Do you feel stressed at work?

Yes No

Do you exercise?

No 1-3 times per week More than 3 times/week

What kind of exercise? For how long?

Is there a spiritual practice or belief system meaningful to you?

Yes No

Daily Nutrition

Question	Never	Rarely	Sometimes	Often	Always

Stress and Safety

Social Support

How do you deal with conflict in your family? Who provides emotional support? Other providers involved in your care Other issues you would like to discuss

Problem List

Please rate how you have been feeling during the past week, including today.

Symptom	None	Mild	Moderate	Marked	Severe

Past tests you have had done Testing you would like to have done

Epworth Sleepiness Scale

Age Sex

Choose 0 for would never doze, 1 for slight chance, 2 for moderate chance, or 3 for high chance.

Situation	0	1	2	3

Contact Information

Past Medical History

Family History

Social History

Daily Nutrition

Stress and Safety

Social Support

Problem List

Epworth Sleepiness Scale

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