New Patient Intake Form Thank you for your interest pursuing health at the Riordan Clinic. As ‘Co-learners’ you will work with the doctors and staff to understand your whole health picture; therefore, we ask for a significant history prior to our initial visit. Thank you for taking the time to thoughtfully complete this form. We look forward to discussing your personal health history from this holistic/detective perspective (looking for root causes.) See you at our first visit! Thank you, The Riordan Clinic Team Name: Date: Address: Age: City: State: Telephone # (home): Gender: M F Zip Code: (work): (Cell): Email Address: Date of Birth: Education: Marital Status: Live with: Married Separated Divorced Widowed Single # Children Spouse Partner Parents Children Friends Alone: Occupation: Hours per week: Employer: Work Address: Retired: How did you hear about The Riordan Clinic and/or who can we thank for referring you? Emergency Contact: Relationship: Address: Phone: What are your most important health problems? List in order of importance. 1. 2. 3. 4. 5. Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 1 of 9 Riordan Clinic - New Patient Intake Form The following questions will help us understand your expectations. 1. Why did you choose to come to The Riordan Clinic? 2. What aspect of holistic / nutritional approach appeals to you? 3. As the process of assessment, planning, intervention, and follow-up progresses, how will you know you are better? What will you be able to do that you can't do now? 4. What is your present level of commitment to address any underlying causes of your health concerns that relate to your lifestyle? (Rate 1-10 = 100% committed) 1 2 3 4 5 6 7 8 9 10 5. What lifestyle habits do you currently engage in that you believe support your health? 6. What lifestyle habits do you currently engage in that you believe harm your health? 7. What beliefs/obstacles do you foresee that could undermine your progress? 8. What else is important to you that we (the Riordan Clinic doctors and staff) should be aware of as we begin working together with you as co-learners? Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 2 of 9 Riordan Clinic - New Patient Intake Form Cancer History Primary Cancer Secondary Cancer (ie. Metastasis) Onset Date Onset Date Location Location Initial Stage Stage Current Stage Previous Treatments (ie. Surgery, Chemo, Radiation) Type Started Ended Previous Treatments (ie. Surgery, Chemo, Radiation) Type Started Family History Father Mother Siblings Maternal Grandparents Paternal Grandparents Spouse Children Age if living: Age when Died: Reason for Death: If Cancer, type: If present, mark an “X” Thyroid Disorder High Blood Pressure Heart Attach Asthma / Allergies Mental Illness Autoimmune Diabetes Osteoporosis Other Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 3 of 9 Riordan Clinic - New Patient Intake Form Doctor, Hospitalization, Surgery, Imaging Primary Care Physician (name and phone #) Please Note when and why you have had each of the following: X-Rays: MRI/CT Scans: Ultrasounds: EKG: Last Dental Visit: Last Eye Exam: Surgery: Allergies Are you hypersensitive to: Any drugs? Any foods? Any substances in the environment or chemicals? Have you ever had allergy testing? (If yes, indicate when and details) Current Medications/Supplements Please list any prescription, over the counter medications, or vitamins/supplements you are taking and dosages: OTC Medications Prescription Medications (ibuprofen, antacids, sleep aids, Vitamins/Supplements laxatives, etc.) 1. 1. 1. 2. 2. 2. 3. 3. 3. 4. 4. 4. 5. 5. 5. 6. 6. 6. 7. 7. 7. 8. 8. 8. 9. 9. 9 10. 10. 10. Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 4 of 9 Riordan Clinic - New Patient Intake Form Health Assessment General Information (Y) = Yes (N) = No (P) = in the Past Current Height: Weight: Maximum Weight: Weight 1 Year Ago: When: Ideal Weight: Do you have sufficient energy throughout the day? Please rate your energy from 1-10 (best)? 1 2 Y N 3 4 5 6 7 8 9 10 When is your energy best? When is your energy worst? Habits/Lifestyle (Y) = Yes (N) = No (P) = in the Past Main interests and hobbies: Do you exercise? Y N If yes, what kind/how often Hours of sleep each night Enjoy your work? YN Sleep well? YN Take vacations? YN Awake rested? YN Spend time outside? YN Have a supportive relationship? YN How many hours of TV per day? Have a history of abuse? YN How much time/day in relaxation? Been treated for drug dependence? YN Do you eat 3 meals a day? YN Use Alcoholic beverages? YN Do you go on diets often? YN Treated for alcoholism? YNP Do you eat out often? YN Do you use tobacco? YNP Do you drink coffee? YNP Do you drink soda/pop? YN How many years and packs/day? Have a religious/spiritual practice? YNP If yes, quantity per day or week Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 5 of 9 Riordan Clinic - New Patient Intake Form REVIEW OF SYSTEMS (Y) = Yes (N) = No (P) = in the Past Mental / Emotional Treated for emotional problems YNP Depression YNP Mood Swings YNP Anxiety or nervousness YNP Considered/Attempted suicide YNP Tension YNP Poor concentration YNP Memory problems YNP Immune Reactions to immunizations YNP Chronic infections YNP Chronic Fatigue YNP Slow wound healing YNP Chronically swollen glands YNP Endocrine (Hormone System) Underactive thyroid YNP Heat or cold intolerance YNP Low blood sugars YNP Excessive hunger YNP Excessive thirst YNP Seasonal depression YNP Fatigue YNP Night Sweats YNP Neurologic Seizures YNP Paralysis YNP Muscle weakness YNP Numbness or tingling YNP Loss of memory YNP Loss of balance YNP Vertigo or dizziness YNP Motion Sickness YNP Skin Rashes YNP Eczema/Hives YNP Acne YNP Itching YNP Color changes YNP Hair loss YNP Lumps YNP Brittle YNP Dry skin YNP Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 6 of 9 Riordan Clinic - New Patient Intake Form Head/Neck Headaches YNP Jaw/TMJ problems YNP Migraines YNP Lumps YNP Head injury YNP Swollen glands YNP Eyes Spots in Eyes YNP Cataracts YNP Impaired vision YNP Glasses/contacts YNP Blurriness YNP Eye pain/strain YNP Color blindness YNP Tearing or dryness YNP Double vision YNP Glaucoma YNP Ears Impaired hearing YNP Ringing in the ears YNP Earaches YNP Dizziness YNP Nose and Sinuses Frequent colds YNP Nose Bleeds YNP Stuffiness YNP Hay fever/Post Nasal Drip YNP Loss of smell YNP Sinus problems Mouth and Throat Frequent sore throat YNP Copious saliva YNP Teeth grinding YNP Sore tongue/lips YNP Gum problems YNP Hoarseness YNP Dental cavities YNP Respiratory Cough YNP Pain on breathing YNP Spitting up blood YNP Shortness of breath YNP Asthma YNP Shortness of breath lying down YNP Pneumonia YNP Bronchitis YNP Emphysema YNP Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 7 of 9 Riordan Clinic - New Patient Intake Form Cardiovascular Heart disease YNP Swelling in ankles YNP High Blood pressure YNP Chest pain YNP Blood clots YNP Murmurs YNP Phlebitis YNP Fainting YNP Rheumatic fever YNP Palpitations YNP Gastrointestinal Trouble swallowing YNP Heart burn/reflux YNP Change in thirst YNP Abdominal pain/cramps YNP Change in appetite YNP Belching or passing gas YNP Nausea/vomiting YNP Constipation YNP Ulcer YNP Diarrhea YNP Yellow skin YNP Bowel Movements per day Gall bladder disease YNP Black stools YNP Liver disease YNP Blood in stool YNP Hemorrhoids YNP Urinary Pain on urination YNP Increased frequency YNP Frequency at night YNP Inability to hold urine stream YNP Frequent infections YNP Kidney stones YNP Musculoskeletal Joint pain or stiffness YNP Arthritis YNP Broken bones YNP Weakness YNP Muscle spasms/ cramps/ pain YNP Sciatica YNP Osteoporosis / Osteopenia YNP Blood Vessels Easy bleeding or bruising YNP Anemia YNP Deep leg pain YNP Cold hands/feet YNP Varicose veins YNP Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org Page 8 of 9 Riordan Clinic - New Patient Intake Form Male Reproductive Hernias YNP Prostate disease YNP Testicular pain YNP Discharge or sores YNP Are you sexually active YNP Sexually transmitted disease YNP Impotence YNP Testicular masses YNP If yes, which one(s): Female Reproductive/Breasts Age of first menses Birth Control Age of last menses (if menopausal) YNP What type: Length of cycle (days) Number of pregnancies Duration of menses (days) Number of live births Are cycles regular YNP Number of miscarriages Bleeding between cycles YNP Number of abortions Painful menses YNP Endometriosis YNP Heavy or excessive flow YNP Ovarian cysts YNP PMS YNP Breast lumps YNP Nipple discharge YNP If yes, what are your symptoms Last pap smear Last mammogram Pain during intercourse YNP Have you had a bone density scan Riordan Clinic ● 3100 N Hillside ● Wichita, KS 67219 Phone 316-682-3100 ● Medical Records Fax 316-618-8537 ● www.riordanclinic.org YN Page 9 of 9
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