pt. assessment form 1:12

Name:___________________________________________Date:__________________________ Address:_________________________________________DOB:__________________________ _________________________________________________________________________________ Home Phone:_________________________________Work/Cell Phone:__________________ Email:________________________________________Occupation:_______________________ Employer:_______________________________________________________________________ Responsible Party (if other than client):___________________________________________ Name:_________________________________________Relationship:_____________________ Address:________________________________________________________________________ Home Phone:_________________________________Work/Cell Phone__________________ Email:________________________________________Occupation:______________________ Physician:____________________________________Phone:____________________________ Referral Source:_________________________________________________________________ Primary Health Concern:________________________________________________________(reason for consult) __________________________________________________________ __________________________________________________________ Other Health Concerns:_________________________________________________________ _________________________________________________________ __________________________________________________________ __________________________________________________________ _____________________________________________________________________________________________ Height_________Weight_________ Recent Weight Changes?_____________________________ Do You Consider Yourself: Very OverWt.☐ Overweight☐ Normal Wt.☐ UnderWt.☐ Rate Your Stress: Very High☐ High☐ Medium☐ Low☐ Very Low☐ Alcohol ________drinks/day/wk Caffeine__________cups day/wk Smoke Y N Food/Medication Allergies/Sensitivities:_____________________________________________ Special Dietary Practices:___________________________________________________________ List Surgeries/Accidents:___________________________________________________________ ____________________________________________________________________________________ Have You Had Prolonged or Regular Use of Any of the Following Medications: ___NSAIDS (Advil, Aleve, Motrin, Asprin)___Tylenol___Antibiotics___Antacids or acid blockers (Zantac, Tagamet Prolisec, Prevacid, Nexium) Do experience any of the following:___Head Aches _____________________________________________________________________________________________ Please Check Pertinent Medical Conditions: Gastrointestinal
Inflammatory/Autoimmune
Metabolic/Endocrine
___Diabetes Type 1 Type 2
Cardiovascular
Musculoskeletal/Pain
Neurological
Cancer (please list type and treatment)
Other
___Asthma
Genetic Testing (note results)
Lab Work: Please bring a copy of any lab work done in the past 6-12 months to your appointment.
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Source: http://nourishingways.com/sitebuildercontent/sitebuilderfiles/_pt._assessment_form_112.pdf