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Functional Medicine Patient Intake
We are excited you have chosen us to assist you with your condition. Please fill out the information below as completely
as possible so the Doctor(s) may properly evaluate you. If you need assistance, please ask the front desk!
Confidential Patient Information PLEASE PRINT LEGIBLY
Legal Name_____________________________________________________________________________________
Address_______________________________________City ________________________State_______ Zip________
Cell Phone ________________________________ Email _________________________________________________
Birth Date_____________________ Age_______ Male Female Social Security #________________________
Occupation________________________________________ Employer ______________________________________
Marital Status: Married Divorced Single Widowed
Emergency Contact ___________________________________ Phone # _____________________________________
What Brought You to Our Clinic?
- Patient Name: ____________________ r? Name: _______________
– Channel? _______________ – Station?______________________
Were you satisfied with your care? YES
Current Health
Are you receiving care from other health professionals? YES
If yes, please name them and their speciality_____________________________________________________________
Please list any drugs or medications you are taking, including any vitamins or herbs_______________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you use: Coffee Tea Artificial Sweeteners Sugar Alcohol Cigarettes Recreational Drugs
Are you pregnant? YES
What are your most pressing health concerns?____________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
For how long?______________________________________________________________________________________
Is it: Getting Worse Improving Intermittent Constant Unsure
Current Symptom Levels:
How would you rate your symptoms on average in the last month?
NONE 1 2 3 4 5 6 7 8 9 10 WORST POSSIBLE
If you had to accept some level of symptoms after completion of treatment, what would be an acceptable level?
NONE 1 2 3 4 5 6 7 8 9 10 WORST POSSIBLE
Have you ever suffered from: (please check all that apply)
Dizziness Irritability Neck Pain Buzzing/Ringing in Ear Fatigue
Memory Loss Chest Pain Back Pain Jaw Problems Paralysis
Tension Neck Stiffness Leg Pain Loss of Sleep Blurred Vision
Upset Stomach Nausea Arm/Shoulder Pain Shortness of Breath Depression
Back Stiffness Numbness Allergies Headache/Migraine Fainting
Arm Tingling Constipation Vomiting Abnormal Blood Pressure Vomiting
Back Tingling Liver Problems Leg Pain/Tingling Irregular Heartbeat Ear Pain
Hand Pain/Tingling Hemorrhoids Lung Problems Painful Urination Colitis
Weight Loss Heart Problems Heartburn
Patient History
Condition Past Present Condition Past Present Condition Past Present
Angina/Chest Pain Headaches Night Sweats
Arthritis Heart Problems Numbness
Asthma HIV Paralysis
Balance Problems Irritability Seizures
Broken Bones Joint Stiffness Sleeping Problems
Cancer Joint Swelling Scoliosis
Chills Joint Tenderness Stiffness
Concentration Loss Loss of Sleep Stroke / TIA
Diabetes Lumps Tingling
Dizziness Masses Thyroid Problems
Fatigue Memory Loss Tremors
Fainting Muscle Cramps Vertigo
Fever Muscle Pain Weakness
Gout Nervousness Other Please List:
Informed Consent and HIPAA / Privacy Practices
INFORMED CONSENT I hereby request and consent to the performance of: physical examinations and evaluations and performance of
any tests required to be performed to diagnose my condition(s), and for treatment, including various modes of physical and rehabilitation
therapy, which the doctor will explain to me, and of other procedures on me by or under the supervision of the doctor named below, or
by trained clinic staff, or other licensed doctors who now or in the future treat me while employed by, working, or associated with, or
serving as back-up for the doctor named below, including those working at the clinic or office listed below or any other office or clinic.
I have had, or will when questions arise, take the opportunity to discuss with the doctor named below and/or with other office or clinic
personnel, the nature and purpose of all procedures. I understand that results cannot be guaranteed. I understand and am informed that,
as in any healthcare practice, there are some rare risks to treatment, including, but not limited to: no results, fractures, disc or spine
injuries, strokes, dislocations and sprains.
I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise
judgment during the treatments which the doctor recommends at the time, based upon the facts then known, and is in my best interests.
I have read, or had read to me, the above consent. I have also had an opportunity, or will take the opportunity, to ask questions about its
content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment
for my present conditions(s) and for any future condition(s) for which I seek treatment.
HIPAA. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about
you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by requesting at the front desk.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or
health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
By my signature below, I acknowledge I have had the opportunity to review the Notice of Privacy Practices located at the front desk.
______ Release of Medical Records for My Medical care or as required By Law:
-To health care providers involved in my care
-To State, Federal, and accrediting bodies for required reporting data and/or surveys for compliance
-For purposes of my care and for business operations
______ Assignment of Benefits/Bill My Insurance
-I authorize Select Health of the Twin Cities to send my bills for my medical care and treatment to my insurance
company and/or Medicare or Medicaid for payment. To the extent that my insurance company and or/Medicare/Medicaid is
required to pay the bill under terms of my insurance policy or by law.
-I request that my insurance company and or/Medicare or Medicaid pay Select Health of the Twin Cities and the
providers who are involved in my treatment.
-I consent to the release of my medical records by Select Health of the Twin Cities to my insurance company
and/or Medicare or Medicaid (and organizations working on their behalf) if necessary in order for my bills to be paid.
-I agree to pay for charges not covered by insurance.
-I understand that if I do not check this box, Select Health of the Twin Cities will bill me directly to collect
payment for services rendered.
Please Complete
Patient’s Name________________________Signature___________________________________ Date______________
Name_________________________________________Relationship_________________________________________
(Above named has permission to receive information regarding my records)
_________________________________/__________ ___________________________/_________
If applicable - Translated by Witness to Patient’s Signature Date
Print name(s) of primary doctor(s) treating this patient:
Dr. Jamy Antoine, D.C, Dr. Don Jewell, D.C and/or Dr. Daniel Piper, D.C
Name: ___________________________________________ Age: ______ Sex: _____ Date: ______________ PART I Please list your 5 major health concerns in order of importance:1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________3. __________________________________________________________________________________________4. __________________________________________________________________________________________5. __________________________________________________________________________________________
PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
Metabolic Assessment Form
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
Category I Feelingthatbowelsdonotemptycompletely LowerabdominalpainrelievedbypassingstoolorgasAlternatingconstipationanddiarrhea DiarrheaConstipationHard,dry,orsmallstoolCoatedtongueor“fuzzy”debrisontonguePasslargeamountoffoul-smellinggasMorethan3bowelmovementsdailyUselaxativesfrequently
Category II IncreasingfrequencyoffoodreactionsUnpredictablefoodreactionsAches,pains,andswellingthroughoutthebodyUnpredictableabdominalswellingFrequentbloatinganddistentionaftereating Abdominalintolerancetosugarsandstarches Category III IntolerancetosmellsIntolerancetojewelryIntolerancetoshampoo,lotion,detergents,etc.MultiplesmellandchemicalsensitivitiesConstantskinoutbreaks Category IV Excessivebelching,burping,orbloatingGasimmediatelyfollowingamealOffensivebreathDifficultbowelmovementSenseoffullnessduringandaftermealsDifficultydigestingfruitsandvegetables; undigestedfoodfoundinstools
Category VStomachpain,burning,oraching1-4hoursaftereatingUseantacidsFeelhungryanhourortwoaftereatingHeartburnwhenlyingdownorbendingforwardTemporaryreliefbyusingantacids,food,milk,or carbonatedbeveragesDigestiveproblemssubsidewithrestandrelaxationHeartburnduetospicyfoods,chocolate,citrus, peppers,alcohol,andcaffeine
Category VI RoughageandfibercauseconstipationIndigestionandfullnesslast2-4hoursaftereatingPain,tenderness,sorenessonleftsideunderribcageExcessivepassageofgas
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 3
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 3
Category VI (continued)Nauseaand/orvomitingStoolundigested,foulsmelling,mucouslike, greasy,orpoorlyformedFrequenturinationIncreasedthirstandappetite
Category VII Greasyorhigh-fatfoodscausedistressLowerbowelgasand/orbloatingseveralhours aftereatingBittermetallictasteinmouth,especiallyinthemorningBurpy,fishytasteafterconsumingfishoilsDifficultylosingweightUnexplaineditchyskinYellowishcasttoeyesStoolcoloralternatesfromclaycoloredto normalbrownReddenedskin,especiallypalmsDryorflakyskinand/orhairHistoryofgallbladderattacksorstonesHaveyouhadyourgallbladderremoved?
Category VIIIAcneandunhealthyskinExcessivehairlossOverallsenseofbloatingBodilyswellingfornoreasonHormoneimbalancesWeightgainPoorbowelfunctionExcessivelyfoul-smellingsweat
Category IX CravesweetsduringthedayIrritableifmealsaremissedDependoncoffeetokeepgoing/getstartedGetlight-headedifmealsaremissedEatingrelievesfatigueFeelshaky,jittery,orhavetremorsAgitated,easilyupset,nervousPoormemory/forgetfulBlurredvision
Category XFatigueaftermealsCravesweetsduringthedayEatingsweetsdoesnotrelievecravingsforsugarMusthavesweetsaftermealsWaistgirthisequalorlargerthanhipgirthFrequenturinationIncreasedthirstandappetiteDifficultylosingweight
0 1 2 3
0 1 2 30 1 2 30 1 2 3
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)
PART IIIHowmanyalcoholicbeveragesdoyouconsumeperweek?Howmanycaffeinatedbeveragesdoyouconsumeperday?Howmanytimesdoyoueatoutperweek?Howmanytimesdoyoueatrawnutsorseedsperweek?Listthethreeworstfoodsyoueatduringtheaverageweek:Listthethreehealthiestfoodsyoueatduringtheaverageweek:PART IVPlease list any medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
Category XI CannotstayasleepCravesaltSlowstarterinthemorningAfternoonfatigueDizzinesswhenstandingupquicklyAfternoonheadachesHeadacheswithexertionorstressWeaknails
Category XIICannotfallasleepPerspireeasilyUnderhighamountofstressWeightgainwhenunderstressWakeuptiredevenafter6ormorehoursofsleepExcessiveperspirationorperspirationwithlittle ornoactivity
Category XIII EdemaandswellinginanklesandwristsMusclecrampingPoormuscleenduranceFrequenturinationFrequentthirstCravesaltAbnormalsweatingfromminimalactivityAlterationinbowelregularityInabilitytoholdbreathforlongperiodsShallow,rapidbreathing
Category XIVTired/sluggishFeelcold―hands,feet,alloverRequireexcessiveamountsofsleeptofunctionproperlyIncreaseinweightevenwithlow-caloriedietGainweighteasilyDifficult,infrequentbowelmovementsDepression/lackofmotivationMorningheadachesthatwearoffasthedayprogressesOuterthirdofeyebrowthinsThinningofhaironscalp,face,orgenitals,orexcessive hairlossDrynessofskinand/orscalpMentalsluggishness
Category XVHeartpalpitationsInwardtremblingIncreasedpulseevenatrestNervousandemotionalInsomniaNightsweatsDifficultygainingweight
Category XVIDiminishedsexdriveMenstrualdisordersorlackofmenstruationIncreasedabilitytoeatsugarswithoutsymptoms
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 3
Category XVII IncreasedsexdriveTolerancetosugarsreduced“Splitting”-typeheadaches
Category XVIII (Males Only)UrinationdifficultyordribblingFrequenturinationPaininsideoflegsorheelsFeelingofincompletebowelemptyingLegtwitchingatnight
Category XIX (Males Only)DecreasedlibidoDecreasednumberofspontaneousmorningerectionsDecreasedfullnessoferectionsDifficultymaintainingmorningerectionsSpellsofmentalfatigueInabilitytoconcentrateEpisodesofdepressionMusclesorenessDecreasedphysicalstaminaUnexplainedweightgainIncreaseinfatdistributionaroundchestandhipsSweatingattacksMoreemotionalthaninthepast
Category XX (Menstruating Females Only)PerimenopausalAlternatingmenstrualcyclelengthsExtendedmenstrualcycle(greaterthan32days)Shortenedmenstrualcycle(lessthan24days)PainandcrampingduringperiodsScantybloodflowHeavybloodflowBreastpainandswellingduringmensesPelvicpainduringmensesIrritableanddepressedduringmensesAcneFacialhairgrowthHairloss/thinning
Category XXI (Menopausal Females Only)Howmanyyearshaveyoubeenmenopausal?Sincemenopause,doyoueverhaveuterinebleeding?HotflashesMentalfogginessDisinterestinsexMoodswingsDepressionPainfulintercourseShrinkingbreastsFacialhairgrowthAcneIncreasedvaginalpain,dryness,oritching
0 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3
Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)
Rateyourstresslevelonascaleof1-10duringtheaverageweek:Howmanytimesdoyoueatfishperweek?Howmanytimesdoyouworkoutperweek?