Female Patient Intake Form | Parker Nutritional Healing Center

Part I: Chief Health Concerns

Please list your 5 major health concerns in order of importance:

1

2

3

4

5

Part II: Symptom Assessment

Instructions: Please select the appropriate number for all questions below:
0 = Least/Never | 1 = Occasionally | 2 = Frequently | 3 = Most/Always

Part III: Lifestyle Assessment

How many alcoholic beverages do you consume per week?

Rate your stress level on a scale of 1-10 during the average week:

How many caffeinated beverages do you consume per day?

How many times do you eat fish per week?

How many times do you eat out per week?

How many times do you work out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Part IV: Current Medications & Supplements

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Part V: Patient Information & Health History

Personal Information

Full Name *

Email Address *

Cell Phone *

Address

City

State

ZIP Code

Date of Birth

Height

Weight (lbs)

Chief Complaint

What is your major complaint? (be as specific as possible)

When did your condition/symptoms/pain first appear?

Reproductive Health History

Are your periods regular?

Yes

No

N/A (Post-menopausal)

Have you gone through menopause?

Yes

No

Medical History

Have you had or do you have any of the following? (check all that apply)

Arthritis

Diabetes

Heart Disease

High Blood Pressure

Other medical conditions not listed: