Step 1 of 6 16% Personal InformationPlease complete the following intake form to the best of your abilities. For non-required questions, please leave blank if you do not have the requested information or the question doesn't apply. Name* First Last Age*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneMobile Phone*Email* Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height*Weight*Occupation*Employer*Business PhoneSpouse Name First Last Spouse EmployerSpouse Business PhoneWho should we contact in case of an emergency?*Emergency Phone*Who is your primary care physician?Primary Care PhoneWho should we thank for referring you?How did you hear about Restorative Health Solutions? Website Internet Search Friend Doctor Referral Health Lecture Other Health GoalsDo you think your condition and/or symptoms can be improved?*What are you looking for in a health care provider?*What do you feel is a reasonable amount of time to see changes with Dr. Warren or Dr. Paul?*Is family/spouse supportive of you seeking care with Dr. Warren or Dr. Paul?*How has this condition negatively impacted your life?*If you get better, how will your life change?*In order to improve you health, are you will to significantly modify your diet?*In order to improve your health, are you willing to significantly modify your lifestyle?*In order to improve your health, are you will to take several nutritional supplements each day?*Are you able to take capsules or tablets, or do you require liquid supplements?* Description of Issue(s)Chief Complaint*Please describe you symptoms: Please indicate how severe each symptom is with 10 being the most severe and 1 being not very severe. What do you think is causing your present health problem(s)?*History of Present Illness*When did your symptoms first occur? Have your symptoms gotten better, worse, or stayed the same since they started? What have you done and who have you seen to help you with this problem?Past Experience*Have you ever been to a chiropractic or functional medicine clinic? If so, how was your experience? Based on your experience, what did you like/dislike?Past Medical HistoryMedical History*Do you have any diagnosis including, but not limited to, your current complaint? Who gave you the diagnosis?Hospitalization HistoryPlease list any hospitalizations with dates and reasons.Hospitalization AnsweredHospitalization BlankMajor Illness HistoryPlease list any major illness you have had with date.Major Illness AnsweredMajor Illness BlankSurgical History*Please list every surgery you have had, the date of each surgery, and the reason for it.Gynecological HistoryPlease list number of pregnancies, delivers, types of delivery, and dates of delivery.If there any chance you are pregnant? When was your last Menstrual Period?Family History*Please list family history of health conditions including grandparents, parents, brothers and sisters. Social HistoryPlease indicate your familial status*singlemarrieddivorcedwidowedHow many kids do you have?*012345+Do you smoke?*non-smokersmokerprevious smokerSmoker HiddenSmoker Hidden PeriodHow long have you smoked?*1-5 years5-10 years10-15 years15-20 years20+ yearsDo you drink alcoholic beverages?*non-drinkerdrinkerDrinker HiddenHow many drinks per week?*1-5 drinks per week5-10 drinks per week10-15 drinks per week15+ drinks per weekDrinker Hidden 2Drinker Hidden PeriodWhat kind of drinks do you consume?*Do you drink caffeinated beverages?*does not drink caffeinated beveragesdrinks caffeinated beveragesCaffeinated BlankHow many caffeinated beverages do you drink daily?*1-3 drinks daily3-5 drinks daily5+ drinks dailyCaffeinated Blank 2Caffeinated Blank PeriodWhat kind of caffeinated beverages do you drink?*Are you sexually active?*sexually activenot sexually activeSexually BlankSexually Blank PeriodHave you been diagnosed with a STD or VD?*not been diagnosedbeen diagnosedSexually Blank 2 AllergiesPlease list all allergies or immune intolerances you have, how you know (if you were tested what type), and what type of reaction you get.Allergies BlankCurrent MedicationsList all current MEDICATIONS and dosages. Tell what you are taking each one for and if its is working well for you or not.Current Meds BlankCurrent SupplementsList all current SUPPLEMENTS and dosages. Tell what you are taking each one for and if it is working well for you or not.Current Supplements BlankSupplement/Medication HistoryList past medication, supplements you have taken and if they worked well for you or did not work well for you.Supplement/Medication BlankActivities of Daily Living (ADL's)*Please write out what a typical weekday looks like for you. Please write out what a typical weekend day looks like for you. Make sure to include exercise, sleep, and food. Review of SystemsConstitutional HistoryConstitutional*Please indicate if you have had or currently have: (check all that apply) Patient denies a history of constitutional complaints alcoholism anemia cancer HIV/Aids abnormal lumps bumps or masses scarlet fever rheumatic fever syphilis Head/EENT HistoryHead / EENT*Please indicate if you have had or currently have: (check all that apply) Patient denies a history of head/EENT complaints trigeminal neuralgia double vision glaucoma macular degeneration hearing loss ringing in the ears decreased smell goiter thyroid nodules difficulty swallowing Cardio HistoryCardiovascular*Please indicate if you have had or currently have: (check all that apply) Patient denies a history of cardiovascular complaints chest pain congestive heart failure heart attack high blood pressure irregular heart beat stroke swelling in the legs/feet vascular disease Respiratory HistoryRespiratory*Please indicate if you have had or currently have: (check all that apply) Patient denies a history of respiratory complaints asthma bronchitis COPD emphysema shortness of breath wheezing snoring GastrointestinalGastrointestinal*Please indicate if you have had or currently have: (check all that apply) Patient denies a history of gastrointestinal complaints blood in stool c-diff Crohn's ulcerative colitis diverticulitis hemorrhoids liver cirrhosis Genitourinary HistoryGenitourinary*Please indicate if you have had or currently have: (check all that apply) Patient denies a history of genitourinary complaints bladder infections cystitis kidney infections kidney disease urinary tract infections This iframe contains the logic required to handle Ajax powered Gravity Forms.
