AGAPE CLINIC WITH HEART
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Health History Intake
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Indicates required field
Name
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First
Last
Email
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Phone Number
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What are your main issues, life or health concerns now?
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Other lifelong symptoms or concerns you have experienced?
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How long have you experienced your main issue(s)?
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How did you feel before you began experiencing this/these current main issue(s)?
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What are your goals for seeking care at Agape Clinic with Heart?
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MEDICAL
Personal history of any of the following.
Please answer
Yes/No
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Include year of onset.
Liver Disease
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Kidney Disease
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Heart Disease
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Coronary Artery Disease
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Peripheral Vascular Disease
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Myocardial Infarction
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Heart Arrythmias
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Lung Disease: Asthma, COPD/Emphysema, or other
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Diabetes Mellitus
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Allergies: Please list
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Cancer: Please list type.
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Anxiety
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Depression
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Other Psychiatric/Mental Health Condition
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Migraine Headaches
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Cluster Headaches
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Other Headaches
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Thyroid or other Endocrine Condition, please list
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Neuropathy: Please list cause.
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Seizures
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Tics
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Tourette’s
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Stuttering
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Explosiveness
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Medications or Supplements: Please list name, frequency and reason for taking.
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SENSORY
Please rate on a scale of 0 to 5 to symbolize how often you agree with the statement listed.
‘0’ = Never Agree, ‘5’= Always Agree. You may also List DK= Don’t know, or NA= Not applicable.
I anticipate weather changes before they occur:
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I am innovative and or imaginative:
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I feel energy of negative or dangerous environments and I am able to take self- preserving action:
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I anticipate a positive outcome in situations prior to it occurring:
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I feel my need to eat prior to experiencing hunger:
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I have some psychic type abilities:
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I notice environmental aromas or scents before others do:
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Weather changes intensely affect how I feel:
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I feel physical changes in my body such as illness before it fully manifests:
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Some foods cause me not to feel well:
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I enjoy a wide variety of foods:
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Some medications cause me not to feel well:
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I am able to distinguish between relaxation and comfort:
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I will feel poorly if I do not eat when it is necessary:
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I choose to be around people based upon their energy and how I feel with them instead of based upon their status:
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My response to some situations surprise or alarm me:
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I feel the energy, mood, & attention of persons near me:
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People close to me find it challenging to spend time with me:
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I must function at my own speed:
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HARDINESS
Please rate on a scale of 0 to 5 to symbolize how often you agree with the statement listed.
‘0’ = Never Agree, ‘5’= Always Agree. You may also List DK= Don’t know, or NA= Not applicable.
I have great difficulty with the weather:
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Medications cause me great difficulty:
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I have low energy/stamina:
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It takes little stimulation to disturb me:
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I am easily fatigued when having to concentrate and plan:
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Mind or Body discomfort keeps me from completing activities:
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Foods give me great difficulty:
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When I get knocked down by life, I am slow to recover to my baseline:
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QUESTIONS OF THE CENTRAL NERVOUS SYSTEM
Please answer Yes, No or Partially.
Capable of driving a car?
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Yes
No
Partially
Are you able to maintain a close relationship with someone?
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Yes
No
Partially
Are you able to concentrate to study and work?
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Yes
No
Partially
For the issues listed below, please rate how often you are presently bothered by them.
On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
SENSES
Please list (and rate for each pertinent issue) if you have difficulty with any of the following senses:
Vision, sense of smell, hearing, sense of touch, or increased sensitivity to light.
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FEELINGS/EMOTIONS
Please list
On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
Have difficulty with rapid unexplained mood swings?
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Have difficulty with out of the ordinary reactiveness or explosiveness?
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Have difficulty with rapid unexplained onset of fear?
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Have Suicidal thoughts or behaviors?
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ANXIETY
Please list
On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
Feeling Restless
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Cold Feet and hands
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Feeling Irritable
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Heart Beat Irregularity
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Drifting Thoughts
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Difficulty Sleeping at night
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Worrying
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MEMORY
Please list
On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
Forget what was just said or what you just read?
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Have poor mental clarity, or brain fog?
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Forget what you need to do or are trying to do?
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have poor initiative, frequently procrastinate, or have difficulty setting priorities?
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Have difficulty learning from experience?
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MOBILITY
Please list
On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
Have significant limitation of any muscles or limited Range of Motion of any joints in your body?
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have paralysis of any extremity or body part?
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PAIN
Please list
On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
Please list any area of body pain, when it began, and rate it.
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