INTAKE FORM

Name _________________________________________________     Gender _______ Date of Birth ________

Street address: ____________________________________________________________________________

City ________________________________ State _______________ZIP ______________________________

Home phone (         ) -___________________ Alt. phone (            )-_____________________________________

Referred by _______________________________________________________________________________

Person to contact in an emergency __________________________ Phone (___)-________________________

Address ____________________________________________ Relationship to you _____________________

Persons with whom you live and their relationship to you:

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Children:   NO _____    YES____ (Please answer bellow)

Name                                                                                            Age
________________________________________________     _______________

________________________________________________     _______________

________________________________________________     _______________

Occupation or work emphasis _______________________________________ Years of Education _______

Education major or training emphasis________________________________________________________

Employer_________________________________________________ Years worked there _____________

Marital status (i.e. single, married, separated, divorced, living with partner) _________

Spouse/partner name ____________________________ Spouse/partner occupation __________________

Outpatient Medical Record - Please check all those that have occurred at any time.
Head injury___ Learning Problems ___ Alcoholism___ Substance Abuse___Hepatitis___ Chicken Pox___ Rheumatic Fever__Thyroid Problems__ Whooping Cough__ Hernia___Cancer/Tumor___ Poliomyelitis___ Sinus Problems____ Food Tolerance___Speech Problems__ Epilepsy___ Bronchitis___ Measles___ Scarlet Fever___Typhoid Fever___ Hearing Problems___ Asthma___Mumps___Bulimia/Anorexia___ Tuberculoses___ Special Diets___ STD___ Appendicitis___ Hypertension___ Stroke___ Anemia___ Kidney Disease___ Diabetes___ Smallpox___ Tonsillitis___ Pregnancies___Heart Palpitations___ Pneumonia___ Neurological disease________Other __________________________________________
Gastrointestinal problems: __________________________Significant weight loss/gain ____________________________
Allergies (food, drug, other: please list)_________________________ HIV Positive? Yes ____ No ____ How Long? _________

Do you experience any of the following? Abdominal Pain_______ Changes in Appetite_______ Dizziness_______Bed Wetting_________ Headaches______________ Fatigue_________Frequent Urination_____ Fainting Spells___________ Chest Pain______ BreathingProblems_______Nausea_________Colds_______________Nosebleeds____Constipation_____Sore throat___________ Coughs________________ Toothache_______ Menstrual Problems____     Diarrhea_____________ Vomiting_______________ Ear Infection_____ Eye Vision Problems___ Memory Problems ____

 List any of the operations, Medical Procedures or Hospitalizations for medical, psychiatric/emotional, drug or alcohol problems. Please include Dates. _______________________________________________________________________

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Legal Status i.e. Are you currently involved with the criminal justice system? _____________________________________