Medical Forms Kinetic Patterns - Intake Form Please provide information that is as complete as possible. Use the plus sign beside some of the questions to add additional fields. NB: A fee will be charged for ‘no shows’ or cancellations of less than 48 hours. Step 1 of 5 20% Your Doctor at Kinetic Patterns is:Name* First Last Sex*MaleFemaleDate Of Birth - mm/dd/yr*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Home Phone*Work PhoneCell PhoneEmergency Contact Person*Relationship*Current PhysicianReferred By Main ComplaintsMain Complaints*ComplaintHow Long List MedicationsNameStrengthDosageHow Long list all medication and/or injections only - vitamins and other supplements you may list later on.Past Medical HistoryProblemYear include important illnesses, operations, accidents, stressAllergies or ReactionsDrugs, medicinesFoods Medical Complaints Please complete all fields of the questionaire if you know the answerEnergyTired early in the daynonesomesevereExcessive tiredness by early eveningnonesomesevereWeak muscles most of the timenonesomesevereFrequent feeling of too coldnonesomesevereFrequent feeling of too hotnonesomesevereDigestionEating more than is good for younonesomeseverePoor appetitenonesomesevereChange of weight more than 5 lbs. last yearnonesomesevereFrequent heartburn or stomach painsnonesomeseverecramps, boating or gas after eatingnonesomeseverelong-standing diarrheanonesomeseverelong-standing vomitingnonesomeseverelong-standing constipationnonesomeseverechange in bowel habitsnonesomeseverebleeding or very dark bowel movementsnonesomeseverehemorroids or anal itchingnonesomesevereDentalpoor teeth, gums, denturesnonesomeseveregrinding teeth or painful jaw jointnonesomeseverehave you ever had mercury/amalgam fillings?yesnowere your fillings removed?removedstill in placedo you have root canalsnoyesGenito Urinarypain or discomfort passing urinenonesomeseveredifficulty starting or controlling urinationnonesomeseverefrequent urinationnonesomesevere2 or more urinations at nightnoyes3 or more urinary tract infectionsnoyessexual difficulties / infertilitynonesomesevereWomen Onlyperiods heavy or irregularnormalsomeseverenot applicable (i.e. postmenopausal)Cramps during periodnonesomesevereBloating or unwell before periodsnonesomeseverepremenstrual headaches or irritabilitynonesomesevereVaginal infections, irritation, dischargenonesomesevereabnormal pap testnoyesdate of last PAP testnumber of pregnanciesnumber of childrenmenopause symptomsFibroidsnonesomesevereEndometriosisnoyesBirth control or hormone usenoyesOsteoporosis or osteopenianonesomesevereEnvironmentalAre you sensitive to perfumesnonesomesevereAre you sensitive to chemicalsnonesomesevereHave you been exposed to chemicals to chemicalsnonesomesevereRespiratoryShortness of breathnonesomesevereShortness of breath while laying down onlynonesomesevereShortness of breath on physical exertionnonesomeseverePersistent cough or wheezingnonesomesevereCoughing phlegm or bloodnonesomesevereCardiovascularRepeated tightness or pain in chestnonesomesevereHeart beating irregularly or very fastnonesomesevereHigh blood pressurenonesomesevereDizziness, faintingnonesomesevereHeadSevere or frequent headachesnonesomesevereConvulsions, fits, epilepsynonesomesevereBlackouts, collapsenonesomesevereRinging in the ears, deafnessnonesomeseverechanges in taste or smellnonesomeseverefrequent sneezing or hay fevernonesomeseverePersistent or frequent coldsnonesomesevereSinus problemsnonesomesevereNose bleedsnonesomesevereLimbsAching joints, arthritisnonesomeseverenumbness, tingling, shooting painsnonesomesevererepeated cramps or spasms in musclesnonesomeseverepainful varicose veinsnonesomesevereswelling of feet or handsnonesomeseverecold feet or hands most of the timenonesomeseveretroublesome back painnonesomeseveretroublesome neck painnonesomesevereSkinCommon states Dryness Oiliness Acne Recurrent boils Ichiness/rash Hives Eczema/psoriasis Poor wound healing Easy bruising Warts Dandruff Hairloss Excessive hair growth Lumps or swelling under the skin Lumps in the breast or nipple discharge Excessive sweat or body odour Halitosis or bad breath MentalBrain fognonesomesevereLack of ambitionnonesomesevereInability to make decisionsnonesomesevereFeeling depressed, down, upsetnonesomesevereCannot fall asleep, or frequent waking upnonesomesevereDisturbing dreamsnonesomesevereDifficulty socializingnonesomeseverePoor memorynonesomesevereThoughts of suicidenonesomesevereWorrying often about healthnonesomesevereAnxiety about little problems (often?)nonesomesevereFeeling that people want to harm younonesomesevereFeeling uptight and anxious (often?)nonesomesevereShaking or heavy breathingnonesomesevereCannot trust people, doctorsnonesomesevereGetting angry, fits of tempernonesomesevere Please specify the following...Are you or have you ever been anemic?noyesWere you born by cesarean section?noyesWere you born with a medical condition?noyesplease explainDo you have any surgical body parts? (i.e. hip, heart valve, pacemaker, breast implants...)noyesplease explainWhat X-rays, CT scans, MRI have you had?Is there any treatment you refuse because of your beliefs?Have you travelled to a tropical country?noyesHave you received blood transfusion(s)?noyesHave you been tested for AIDS?noyesAre you HIV positive?noyesHave you been tested for Hepatitis?noyesDietDo you eat breakfast?noyesHow many meals do you eat in a day?How many meals daily do you spend 20 minutes or more at a table?How many cups of coffee per day?How many cups of tea per day?How many 12oz servings of pop (1 can/bottle)How many glasses of milk?How many alcoholic beverages?How many cups of water?Have you ever smoked cigarettes?noyesHow long?How many years have you smoked?What is your weight?What is your height?What foods and beverages do you crave strongly?Do you crave sugar or sweet foods?noyes StressDo you have problems coping with marriage or friends?noyesDo you have excessive financial or job security problems?noyesDo you work under pressure?noyesDo you live/work irregular hours?noyesDo you frequently travel or commute long distance?noyesHow often do you relax, meditate, pray, practice yoga, tai-chi?nevernot very oftenonce in a whilefrequentlyExercise / ActivityRate your level of physical activitynot much. sedentarymoderate exerciseactiveDo you feel better after exercise?noyesDo you feel pains or tired after exercise?noyesHistory of Family IllnessPlease include their respective ages.FatherMotherBrothers, SistersGrandparentsChildrenOtherSupplementsvitamins, minerals, herbs, etc.SupplementStrengthDosageHow long Section BreakIs patient 10 years of age or less?noyesWere there difficulties with pregnancy, labour or delivery?Was the child breast fed? And for how long?Any problems with formula feeding?Delayed developments?Had child had immunization shots?Were there frequent infections?Frequent antibiotics? Poor eater Poor sleeper Spitting up Often crying Bed wetting Colicky Rashes Areas of Pain (PDF) Download and print PDF. Then draw on the illustration using pre-defined marks to indicate areas of numbness, severe or moderate pain, spasms, etc.