Wellness & Intake

Adult Wellness Intake

SeaSide Integrative Medical Center WELLNESS AND LIFESTYLE ASSESSMENT Click Here to Print Form

Date
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Full Name
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Address
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Home Phone
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Work Phone
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Mobile phone/other
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Fax
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Best Phone number to reach you:
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SSN
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Email(*)
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DOB
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Age
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Sex
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Height
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Weight
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Marital Status:
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Number of Children
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Occupation
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Pets (please list):
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Emergency Contact
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Relationship
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Address
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Telephone
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PRIMARY INSURANCE INFORMATION

Primary Ins.Co.:
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ID#
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Insurance Address
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Group#
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Relationship to Insured
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DOB
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Gender
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SECONDARY INSURANCE INFORMATION

Primary Ins.Co.:
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ID#
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Insurance Address
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Group#
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Relationship to Insured
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DOB
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Gender
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YOU ARE RESPONSIBLE FOR ANYTHING YOUR INSURANCE COMPANY DOES NOT COVER. ALL COPAYS ARE DUE AND PAYABLE AT THE TIME OF YOUR APPOINTMENT. THE FOLLOWING FEE'S MAY APPLY.

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ALLERGIES (please describe your symptoms):

Seasonal allergies (hay fever, other)
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Medication allergies (rash, other)
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SECTION ONE: Past Medical History – SELF

Neurological
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If other
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Cardiovascular
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If other
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Auto Immune
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If other
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Liver Disease
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If other
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Endocrine
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If other
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Gastrointestinal Ulcers
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If other
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Respiratory
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If other
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General
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If other
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Musculoskeletal
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If other
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Mental Concerns
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If other
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Genitourinary
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If other
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Cancer

Where
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What kind
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When
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HIV/AIDS (symptoms – please explain)
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Other/Explain
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Surgical procedures- (please list any and all major or minor surgical procedures and the dates the procedures were performed):
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Date of last chest x-ray
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Date of last Pap smear/pelvic exam
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Date of last mammogram
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Date of last Pelvic Ultrasound
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Date of last Bone density
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Date of last digital-rectal exam
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Date of last PSA/prostate exam
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Date of last colonoscopy/sigmoidoscopy
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Date of last cardiac stress test and/or EBCT
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SECTION TWO: Medical History – FAMILY

Mother
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Status
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Current age or age at death
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Medical History
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Father
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Status
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Current age or age at death
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Medical History
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Siblings
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Status
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Current age or age at death
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Medical History
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Children
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Status
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Current age or age at death
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Medical History
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Grandchildren
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Status
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Current age or age at death
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Medical History
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SECTION THREE: Your Social History

Where were you born?
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Where did you grow up?
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What kinds of work have you done?
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What kind of work do you do now?
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How many hours do you work each day?
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What are your hobbies?
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What brings you the greatest joy in your life?
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SECTION FOUR: DRUG USE

Marijuana use (how long, how often)
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Alcohol use (how long, how often)
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Tobacco use (what type, how long, how often)
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Cocaine use (mode, how long, how often)
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Psychedelic drug use (Ecstasy, LSD, other)
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Other recreational drug use (what type, how long, how often
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SECTION FIVE: NUTRITION

How many meals do you eat per day?
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How much water do you drink a day?
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What type of diet are you eating?

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Vegetarian Diet

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If other, please explain
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Coffee Number of cups per day
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Tea Type and number of cups per day
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Soft Drinks/Diet Drinks Type and amount per day
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Do you eat foods containing large amounts of sugar?
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Do you use artificial sweeteners such as Equal, Sweet-n-Low or Sucralose?
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Do you use a microwave to cook or reheat your food?
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Typical Daily Food Intake:
List all food consumed in the last TWO days. If these days are not typical, pick two days that are most typical of your eating patterns. Please be specific, including amount of foods and beverages.

breakfast
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time
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food & ammount
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average & ammount
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snack
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time
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food & ammount
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average & ammount
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lunch
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time
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food & ammount
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average & ammount
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snack
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time
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food & ammount
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average & ammount
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dunner
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time
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food & ammount
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average & ammount
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snack
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time
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food & ammount
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average & ammount
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Food Allergies
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List any Food Allergies that you have (be specific and be sure to include ALL food allergies)

 
SECTION SIX: EXERCISE

What type of exercise do you do?

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Please list your specific form(s) of exercise:
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How many times do you exercise each week?
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When you exercise, how long are your exercise sessions:

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After exercising, is your energy better or worse?
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During your exercise sessions is your energy level stable? If not explain.
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SECTION EIGHT: SPIRITUAL

Religion
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Do you practice this religion?
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SECTION NINE: MEDICATION and NUTRITIONAL SUPPLEMENT UTLIZATION

Please list the name(s), dosage, frequency and duration of all medications that you are taking:

Name
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Dosage
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Frequency
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How Long?
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Name
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Dosage
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Frequency
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How Long?
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Name
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Dosage
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Frequency
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How Long?
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Name
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Dosage
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Frequency
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How Long?
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Name
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Dosage
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Frequency
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How Long?
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SECTION TEN - REVIEW OF SYSTEMS (check all that apply)

GENERAL

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SKIN

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HEMATOPOIETIC

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ENDOCRINE

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CENTRAL NERVOUS SYSTEM

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EYES

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EARS

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NOSE,THROASINUSES

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TEETH AND GUMS

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RESPIRATORY

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CARDIOVASCULAR

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GASTROINTESTINAL

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URINARY TRACT

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MUSCULOSKELETAL

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EPRODUCTIVE MALE

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REPRODUCTIVE FEMALE

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PSYCHIATRIC

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If Other
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Enter the Security Code Shown(*)
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