Confidential Intake FormPractitioner: DO NOT send this page with your case study report – for

your records ONLY

Please email this form to mccoysteph@gamil.com

Name: ____________________________ Date of Initial Visit _________________

Address ___________________________________________________

State ___________ Zip ____________________

Phone______________________________

email_________________________________

Date of Birth ____________________ Age __________

Female _____ Male_____ Other________

Preferred Pronoun _______________

Occupation ___________________________________________

Marital/Relationship status __________________________________

Referred by _________________________________________

Revised November 2018

Client Confidentiality and Release FormI understand this modality is not a replacement for medical care. The practi-tioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuti-cals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend re-ferral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.

Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regula-tions require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compli-ant is to obtain this release signature at the initial consultation. Clients should receive a copy of the form they signed (upon request), and the practi-tioner maintains a copy for their records

I, (name) ____________________________________________

give my permission, for my practitioner, to take notes including health his-tory/ medical and /or personal information I choose to disclose to him/her. I understand this information may be used for the purpose of practitioner cer-tification and/or may be shared with the Arvigo Institute, LLC for statistical data collection only. All relevant identifying information will not be disclosed, such as name, address, social security number, date of birth.

Client Signature: ______________________________________ Date: ______________

Practitioner signature ____________________________________________ Date: ___________________

Revised November 2018

Reason For Visit

Primary reason for visit:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

When did your first notice it? ___________________________________________________

What brought it on? _____________________________________________________

Describe any stressors occurring at the time _____________________________________

____________________________________________________________________________

____________________________________________________________________________

What activities provide relief? __________________________________________________

What makes it worse? ___________________________________________________

Is this condition getting worse? ___________________

interfere with work ______. sleep ______ recreation _______

Have you had massage/bodywork before? ______________

What type? ___________________________________

Revised November 2018

For Administrative Use OnlyClient Initials: _________Case Study #_________Age_________ Anatomy: Male ________ Female_________ Date of Visit: __________________ Practitioner Name _____________________________________________

Medical History

Are you currently under the care of another health care provider(s)? _________________

Reason(s) ___________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Name(s) of Practitioner ________________________________________________________

Address ____________________________________________________________________

Phone ______________________ Email __________________________________________

Current Medications and /or Supplements/Remedies: ______________________________

____________________________________________________________________________

____________________________________________________________________________

Allergies: specify allergen and reaction: _________________________________________

____________________________________________________________________________

Surgical History (year and type) and/or Recent Procedures: _________________________

____________________________________________________________________________

____________________________________________________________________________

Hospitalizations: _____________________________________________________________

____________________________________________________________________________

Accidents or Traumas_________________________________________________________

____________________________________________________________________________

Falls/Injuries to Sacrum/head/tailbone (describe) __________________________________

____________________________________________________________________________

____________________________________________________________________________

Revised November 2018

Other: Please review and check the following:

Other (not mentioned above):

Family HistoryStill Liv-ing?

Cause of Death/age of Major Health Issues

Mother

Father

Siblings

Revised November 2018

HeadachesType:

Past Present

Numbness in feet or legs when standing

Past Present

Asthma Sore heels when walking

Cold Hands or feet

Anxiety

Swollen ankles Depression

Sinus ConditionsFrequent Colds

Sleep Disturbance

Seizures Fainting Spells

Low Back Pain Muscular Tension:Location:

Skin Disorders:Type

Varicose VeinsHemorrhoidsLocation

Sciatica Herniated/Bulging Discs

Painful/SwollenJoints

Artificial/Missing limbs

High or Low BloodPressure

Contact Lenses

Dentures/Partials Cancer (past or current)Type

Maternal Grandmother

MaternalGrandfather

Paternal Grandfather

Paternal Grandmother

Page 3

Digestion and Elimination

Typical Breakfast: ____________________________________________________________

Typical Lunch: _______________________________________________________________

Typical Dinner: ______________________________________________________________

Snacks: _____________________________________________________________________

Water Intake (glasses/day) ___________________ Caffeine ____________________

Revised November 2018

Do you use Tobacco? ______ Quantity_____/ppd

Alcohol? ______ Quantity ______ounces/day

Marijuana? _______ Quantity ______

Other: _______________

Have you been under treatment for substance use?

What is the worst item in your diet ______________

What foods are your weakness__________________________

Are you subject to binge eating? _________________________

What foods_________________________________

Do you experience bloating/gas/burps after eating? _____________

What foods trigger this? __________________

How often are your bowel movements? ___________________________

Do your stools: sink ______ float _______

Constipation? _______ Blood in stool? ______

Mucus in stool? ________Pain when stooling? _______

Other concerns: ____________________________________________________________________________

____________________________________________________________________________

EMOTIONAL & SPIRITUAL

What is your opinion of yourself? _______________________________________________

____________________________________________________________________________

If possible, please describe the most negative emotion you experience _______________

____________________________________________________________________________

When do you most often feel this emotion: _______________________________________

Where are you? ________________________________________________________

Do you pray to or have a spiritual practice ________________________________________Revised November 2018

On a scale of 1 – 10 (1 being the lesser, 10 the greater) Please rate yourself:

Faith ________ Hope ________ Charity ________ Generosity ________

Sense of Humor ________ Sense of Fun ________ Fear ________ Grief ________

Other (describe briefly) ___________________________________________________

What are hobbies/ activities that provide you with a sense of pleasure and accomplish-ment?

____________________________________________________________________________

Describe your exercise routine (type, frequency) __________________________________

____________________________________________________________________________

What changes would you like to achieve in 6 months: ______________________________

____________________________________________________________________________

One Year: ___________________________________________________________________

____________________________________________________________________________

Method of Contraception (circle)

pills patch diaphragm injection condoms IUD abstinence rhythm method

Fertility Awareness Other _____________

Length of time using method _________________________________Page 4

Last Pap smear ___________ Results (if known) __________________________________

Are you under the treatment for Infertility _____________

Describe current treatment to date: _____________________________________________

____________________________________________________________________________

(IUI, IVF, etc.) ________________________________________________________________

Revised November 2018

Gynecological Provider: _______________________________________________________

Address ___________________________________________ Phone ___________________

Menstrual History Review and check as indicated:

Age of Menses: __________ What was this like for you? ___________________________

Last Menstrual Period: ____________ Length of Menses_______________

Are you trying to conceive? ___________ Possibility of Pregnancy _______________

Painful Periods Past Present Irregular cyclesEarly Late

Past Present

Heaviness in Pelvis prior to menses

Dark Thick Blood at:BeginningEnd Both

Excessive BleedingPads per Hour

Headache or Migrainewith menses

Dizziness Bloating

Water Retention Ovulation:Painful

Revised November 2018

Reproductive Health History - Female Anatomy

Failure to

EndometriosisLocation (if known)

FibroidsLocation (if known)

Uterine or CervicalPolyps

Uterine Infection(s)

Vaginal Infection(s) CystsLocation:

Bladder Infection(s) Urinary Incontinence

Painful Intercourse Vaginal Dryness

Episodes of Amen-orrhea

How long?

Page 5

Pregnancy History:

Number of Pregnancies:

Number of Births:Dates:

Complications: Miscarriages: Terminations:

Premature Births: Spotting during Pregnancy

Weak Newborns at Birth

Incompetent Cervix

Revised November 2018

Briefly describe your experience with:

Pregnancy: __________________________________________________________________

____________________________________________________________________________

Labor: ______________________________________________________________________

____________________________________________________________________________

Birthing _____________________________________________________________________

____________________________________________________________________________

Post-Partum: ________________________________________________________________

____________________________________________________________________________

Maternal Family History of (please circle)

Infertility Fibroids Endometriosis PMS Menopause

Cancer (type) _____________. Menstrual Problems ______________

Other_________________________________

Medications your mother took when she was pregnant with you (if any)

____________________________________________________________________________

Your Birth Trauma (if known) ___________________________________________________

____________________________________________________________________________

Other:

Rate your interest in Sex:

High_________Moderate__________Low______________None__________

Revised November 2018

Do you have or ever had difficulty experiencing orgasms __________________________

Do you have a history of rape _______ trauma _______ incest _______

If so,-when_____________________________________________________________

Did you undergo counseling for this? ______________________________________

What was this like for you ________________________________________________

Please feel free to share any additional information:

Revised November 2018

Page 6

Menopause

Age symptoms began: ____________

Are they getting worse __________ better ________________ same ___________

Are you on/ or ever been on hormone replacement therapy? ______

if so, how long__________________________

Name and dose_________________________________________________________

Reason for stopping_____________________________________________________

Age of Mother at menopause: ________

Concerns/Experience____________________________________________________

Check the following symptoms that apply to you:

Hot flashes Insomnia Fatigue Memory Loss Mood Swings

Vaginal Dis-charge

Dry Vagina Depression Anxiety Irritability

Spotting Flooding Irregular Menses

Painful Inter-course

Increased Libido

Decreased Li-bido

Disturbed Sleep Pattern

Additional Information:

Revised November 2018

Reproductive Health History - Male Anatomy

Please check the symptoms below that apply

Painful Urination Past Present

Urinary Retention Past Present

Urinary Inconti-nence orDribbling

Difficult starting or holding urine stream

Weak or InterruptedUrine flow

Blood or pus in urine

Pain or Burning withUrination

Pelvic pressure

Nocturnal UrinationHow many times?

Insatiable sex drive

Pain in lower back, esp. after intercourse

Pain or DiscomfortBetween scrotum and testicles

Pain or Discomfort in:PenisTesticlesRectum

Pain or Discomfort in inner thighs:LeftRightBoth

Frequent Bladder orKidney InfectionsWhen?

Erection:Difficulty in Obtain-ingMaintainingPainful ejaculation

Results of PSA (prostate specific antigen) Test if known_________ Date done__________

Results of Sperm count (if applicable and known) ______________ Date done__________

Family History of Prostate Disease: Yes _____ No _____ Type _________________

Relationship _______________________________

Family History of Cancer: Yes _____ No _____ Type _________________

Relationship_______________________________

Sexually transmitted: Yes _____ No _____ Type if Known__________________________

Revised November 2018

Rate your interest in Sex: High ______ Moderate _______ Low ________ None _______

Do you have a history of rape _______ trauma _______ incest ________

If so, when? ____________________________

Did you undergo counseling for this? ___________________________________________ What was this like for you _____________________________________________________

Additional Information you feel important your practitioner should know that is not mentioned here:

Revised November 2018