BIG SKY INTEGRATIVE HEALTH, PC 8707 N. Jackrabbit Ln. Ste. E Belgrade, MT 59714(406) 388-6676Adult Intake Form *Downloadable Form* Name * First Name Last Name Today's date MM DD YYYY Age Date of birth MM DD YYYY Gender Male Female Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Occupation Please add hours worked per week/if you are retired Employer SSN# Emergency contact Relationship Married Separated Divorced Widowed Single Partnership Live with Spouse Partner Parents Children Friends Alone Which doctor referred you How did you hear about us Please fill out completely What Are Your Most Important Health Problems That Your Doctor Is Treating You For? List As Many As You Can In Order Of Importance. Allergies Are you hypersensitive or allergic to anything? Do you use any of the following Antacids Cortisone Tranquilizers Pain Relievers Appetite Suppressors Thyroid Medication Marijuana Tobacco Sleeping Pills Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking Weight Weight 1 year ago Maximum weight and when Height When is your energy... Best Morning Afternoon Evening Worst Morning Afternoon Evening Review of systems -Endocrine Hypothyroid Current Condition Never Had Past Condition Hypoglycemia Current Condition Never Had Past Condition Fatigue Current Condition Never Had Past Condition Heat or cold intolerance Current Condition Never Had Past Condition Diabetes Current Condition Never Had Past Condition Seasonal depression Current Condition Never Had Past Condition -Cardiovascular Heart disease Current Condition Never had Past Condition Palpitations/fluttering Current Condition Never Had Past Condition Hi/low blood pressure Current Condition Never Had Past Condition -Gastrointestinal Heartburn Current Condition Never Had Past Condition Change in thirst Current Condition Never Had Past Condition Belching or passing gas Current Condition Never Had Past Condition Change in appetite Current Condition Never Had Past Condition Bowel movements How often and is this a change Constipation Current Condition Never Had Past Condition Diarrhea Current Condition Never Had Past Condition -Habits Average 6-8 hrs. sleep Yes No Sleep well Yes No Awaken rested Yes No Have a supportive relationship Yes No Any major traumas Yes No Have a history of abuse Yes No Use recreational drugs Yes No Past Condition Treated for drug dependance Yes No Past Condition Do you eat 3 meals a day Yes No Past Condition Do you eat out often Yes No Past Condition Do you go on diets often Yes No Past Condition Do you drink coffee Yes No Past Condition Do you drink tea Yes No Past Condition Do you drink soda/pop Yes No Past Condition Do you eat refined sugar Yes No Past Condition Do you add salt Yes No Past Condition Enjoy your work Yes No Take vacations Yes No Spend time outside Yes No Do you watch television If so, how many hours? Do you read If so, how many hours? Use alcoholic beverages Yes No Past Condition Treated for alcoholism Yes No Past Condition Do you use tobacco Yes No Past Condition What do you feel needs to happen for you to get better Is there any information about your health you would like to add Insurance Primary insured Primary insured DOB Relationship to primary insured ID # Group # **You will sign for this form when you come to the office.** Thank you!
