Intake Form

Health History Intake

* Indicates required field

Name *

First

Last

Email *

Phone Number *

What are your main issues, life or health concerns now? *

Other lifelong symptoms or concerns you have experienced? *

How long have you experienced your main issue(s)? *

How did you feel before you began experiencing this/these current main issue(s)? *

What are your goals for seeking care at Agape Clinic with Heart? *

MEDICAL
Personal history of any of the following. Please answer Yes/No. Include year of onset.

Liver Disease *

Kidney Disease *

Heart Disease *

Coronary Artery Disease *

Peripheral Vascular Disease *

Myocardial Infarction *

Heart Arrythmias *

Lung Disease: Asthma, COPD/Emphysema, or other *

Diabetes Mellitus *

Allergies: Please list *

Cancer: Please list type. *

Anxiety *

Depression *

Other Psychiatric/Mental Health Condition *

Migraine Headaches *

Cluster Headaches *

Other Headaches *

Thyroid or other Endocrine Condition, please list *

Neuropathy: Please list cause. *

Seizures *

Tics *

Tourette’s *

Stuttering *

Explosiveness *

Medications or Supplements: Please list name, frequency and reason for taking. *

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: *

I am innovative and or imaginative: *

I feel energy of negative or dangerous environments and I am able to take self- preserving action: *

I anticipate a positive outcome in situations prior to it occurring: *

I feel my need to eat prior to experiencing hunger: *

I have some psychic type abilities: *

I notice environmental aromas or scents before others do: *

Weather changes intensely affect how I feel: *

I feel physical changes in my body such as illness before it fully manifests: *

Some foods cause me not to feel well: *

I enjoy a wide variety of foods: *

Some medications cause me not to feel well: *

I am able to distinguish between relaxation and comfort: *

I will feel poorly if I do not eat when it is necessary: *

I choose to be around people based upon their energy and how I feel with them instead of based upon their status: *

My response to some situations surprise or alarm me: *

I feel the energy, mood, & attention of persons near me: *

People close to me find it challenging to spend time with me: *

I must function at my own speed: *

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: *

Medications cause me great difficulty: *

I have low energy/stamina: *

It takes little stimulation to disturb me: *

I am easily fatigued when having to concentrate and plan: *

Mind or Body discomfort keeps me from completing activities: *

Foods give me great difficulty: *

When I get knocked down by life, I am slow to recover to my baseline: *

QUESTIONS OF THE CENTRAL NERVOUS SYSTEM
Please answer Yes, No or Partially.

Capable of driving a car? *

Are you able to maintain a close relationship with someone? *

Are you able to concentrate to study and work? *

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. *

FEELINGS/EMOTIONS
Please list On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.

Have difficulty with rapid unexplained mood swings? *

Have difficulty with out of the ordinary reactiveness or explosiveness? *

Have difficulty with rapid unexplained onset of fear? *

Have Suicidal thoughts or behaviors? *

ANXIETY
Please list On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.

Feeling Restless *

Cold Feet and hands *

Feeling Irritable *

Heart Beat Irregularity *

Drifting Thoughts *

Difficulty Sleeping at night *

Worrying *

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? *

Have poor mental clarity, or brain fog? *

Forget what you need to do or are trying to do? *

have poor initiative, frequently procrastinate, or have difficulty setting priorities? *

Have difficulty learning from experience? *

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? *

have paralysis of any extremity or body part? *

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. *

SEND

Health History​Intake Form

Health History Intake

Health History
Intake Form