This form is secure. 

New Client Intake Questionnaire

My mission is to assist you with progress towards your goals of well-being. To facilitate this, please complete the following questionnaire. This information will be kept confidential by standards that equal to those required by HIPAA.

Instructions: Please answer all of the following questions as completely as possible. NOTE: If you leave this form, click on the Save Progress button in the top left corner of this page and follow the instructions. You will have 7 days to return to the form before it expires.
 

First Name
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Email Address
Telephone Number

What are your goals for treatment?

(Describe all the things you would like to have change, whether or not these are likely to be part of treatment here. For items, which I may not be able to directly assist you with, I may be able to make referrals.)

What do you consider to be your health strengths?

What do you consider to be your health challenges?

Date of Birth
Present Age
Height
Weight
Gender
Relationship Status    Other: 
What is your occupation?
How long have you worked at this occupation?

What aspects do you find pleasing or satisfying?

What aspects do you find stressful or unsatisfying?

How would you rate the ratio of positives to negatives for your occupation?

Pets

List and describe all domestic animals/pets in your household:

Diet

Describe your diet:

Tobacco Use

Do you currently smoke tobacco? YesNo
In what form?
How much/How often?
Past smoker? When quit?
In what form?
How much/How Often?

Alcohol Use

Do you currently drink alcohol? Yes    No
In what form?
Typical number of drinks per day?
Per week?
Did you quit alcohol? When?
In what form?
Typical number of drinks per day?
Per week?

Exercise

List all kinds of exercise you normally do; include typical frequency & duration of each activity:

Stress

How stressful do you feel your life is currently? Please describe the stressors in your life.

Practitioners

Please write down a list of the names and contact information for all practitioners you see. Please include all: Medical Doctors, MD, Osteopaths, DO, Naturopaths, ND, Chiropractors, DC, Oriental Medical Doctors, OMD, Physicians Assistants, PA, Nurse Practitioners, NP, Physical Therapists, PT, Occupational Therapists, OT, Acupuncturists, LaC, Massage Therapists, LMT, Mental Health practitioners, MD, PHD PsyD, MA, MS, LPC, MSW, etc., Ayurvedic practitioners, Tibetan Medical practitioners, Herbalists, Energy healers, Spiritual healers, Shaman, Bone Setters, Native American healers, and All others

Sleep Patterns

How well do you feel you sleep? Describe in detail:

How well rested do you usually feel when you wake up in the morning?

How easy is it for you to get to sleep?

How well do you usually stay asleep?

What time do you usually go to bed?

Is your bedtime fairly consistent or rather variable?

What time do you usually get up?

Do you usually get up around the same time, or is wake up time quite variable?

How often do you take naps during the day?

How much do you snore?

Are you aware of having any sleep apnea?

If so, is the apnea obstructive or central?

Medications

Write down a list of:

  • All pharmaceutical medications you may be taking, with dosages & frequency
  • All supplements and herbs you currently take with dosages & frequency
  • All homeopathic remedies, ayurvedic preparations, or other alternative and / or complementary substances you may currently be taking.

Health History

Please describe your health history completely going back to earliest childhood:

What do you know about your own birth, and about your mother's pregnancy with you?

Write down all surgeries you have ever had, type of surgery & date:

How successful do you feel the surgery was?

Are you aware of any continuing effects from the surgery, and if so what?



What xrays, CT scans, MRI, Arthrogram, Diagnostic Ultrasound or other imaging have you had in the past 5 years. For each, please list date, type of imaging, part of body and facility where imaging done.


 

Describe all significant injuries including: Cuts, Burns, Broken bones, Whiplash, Concussions & other Impact injuries, Hard Falls, Crush Injuries, Piercing Injuries including gun shot wounds.

Describe all motor vehicle accidents you have been in with at least approximate dates.

Describe illnesses you have had: For each illness include dates, treatment and outcome. Include illnesses of all types including: Infectious, Metabolic, Inherited, Mental, Other

Describe any congenital oddities or abnormalities you may have.

Describe any adverse reactions you have had to medications.

Are you aware of any food allergies or sensitivities? Please list all.

Please list all other known allergies.

Is there any mold in your home or workplace? If so, describe:


When did you last have a complete medical physical exam?

With which provider?



For Women Only:
Are you currently pregnant? If so, what is your due date?
Please describe your history of pregnancies & child births. For each event, please give at least
approximate dates, as well as the course of the event and outcome.

Are you planning on becoming pregnant?

Do you have an IUD?

Do you have Essure birth control?

 

How did you learn about this practice?

Please assist us by taking a moment to complete this questionnaire. Your input is vital in improving our communications.

Online Search

Please list the terms used in your search (ie, rolfing or craniosacral):

Printed Advertising



Other:

Online Directories





Other:

Referral

Who?

Web Site Feedback

How useful was my website www.jeffreyburch.com to you?

What did you like about it?

Any suggestions for improving?

Submit Form 

NOTE: If you want to print a copy of your intake questionnaire, you must do so prior to clicking on the Submit button and you must print from your internet browser.