Immune Deficiency Disease Multiple Chemical Sensitivities ☐ ☐ Herpes-Genital Other ______________________________________ ☐ ☐ / CONDITIONS (Continued) Check appropriate box and provide date of first symptoms Respiratory Diseases Asthma Pneumonia ☐ ☐ Chronic Sinusitis Tuberculosis ☐ ☐ Bronchitis Sleep Apnea ☐ ☐ Emphysema ___________________________________ ☐ ☐ Skin Disease Eczema Melanoma ☐ ☐ Psoriasis Skin Cancer ☐ ☐ Acne Other ____________________________________ ☐ ☐ Neurologic / Mood Depression Mild Cognitive Impairment ☐ ☐ Anxiety Memory Problems ☐ ☐ Bipolar Disease Parkinson’s Disease ☐ ☐ Schizophrenia Multiple Sclerosis ☐ ☐ Headaches ALS ☐ ☐ Migraines Seizures ☐ ☐ ADD / ADHD Other Neurological Problems____________________ ☐ ☐ Autism ☐ Preventive Test Check box if yes and provide date that the test was administered. – Full Physical Exam Hemoccult Test (Stool tested for blood) ☐ ☐ Bone Density MRI ☐ ☐ Colonoscopy CT Scan ☐ ☐ Cardiac Stress Test Upper Endoscopy ☐ ☐ EBT Heart Scan Upper GI Series ☐ ☐ EKG Ultrasound ☐ ☐ Injuries Check box if yes and put date next to it – Back Injury Head Injury Neck Injury Broken Bones ☐ ☐ ☐ ☐ Other: _______________________________________________________________________________________________________
☐ Immune Deficiency Disease ☐ Multiple Chemical Sensitivities ☐ Herpes-Genital ☐ Other ______________________________________ / CONDITIONS (Continued) Check appropriate box and provide date of first symptoms Respiratory Diseases ☐ Asthma ☐ Pneumonia ☐ Chronic Sinusitis ☐ Tuberculosis ☐ Bronchitis ☐ Sleep Apnea ☐ Emphysema ☐ ___________________________________ Skin Disease ☐ Eczema ☐ Melanoma ☐ Psoriasis ☐ Skin Cancer ☐ Acne ☐ Other ____________________________________ Neurologic / Mood ☐ Depression ☐ Mild Cognitive Impairment ☐ Anxiety ☐ Memory Problems ☐ Bipolar Disease ☐ Parkinson’s Disease ☐ Schizophrenia ☐ Multiple Sclerosis ☐ Headaches ☐ ALS ☐ Migraines ☐ Seizures ☐ ADD / ADHD ☐ Other Neurological Problems____________________ ☐ Autism Preventive Test – Check box if yes and provide date that the test was administered. ☐ Full Physical Exam ☐ Hemoccult Test (Stool tested for blood) ☐ Bone Density ☐ MRI ☐ Colonoscopy ☐ CT Scan ☐ Cardiac Stress Test ☐ Upper Endoscopy ☐ EBT Heart Scan ☐ Upper GI Series ☐ EKG ☐ Ultrasound Injuries – Check box if yes and put date next to it ☐ Back Injury ☐ Head Injury ☐ Neck Injury ☐ Broken Bones Other: _______________________________________________________________________________________________________
Intake-Form-2018-2019-Adult-14-FINAL.docx