Intake Form

KC Wellness Center Medical Intake Form

Please fill out the form below. You will asked to sign this form, medical forms release and our confidentiality agreement upon your first visit.

NOTE: Your health information will be kept strictly confidential. Any information that we collect about you on this form will be kept confidential in our offices. You can also download and fill out the form HERE

Thanks!

Intake Form

Step 1 of 6

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Instructions:

1. Please fill out the patient intake form below and submit it.
2. A representative from KC Welnness Center will follow up with you shortly.

Name(Required)

First Middle Last

DOB(Required)

Age(Required)

Social Security Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Employer(Required)

Gender(Required)

Male

Female

Marital Status(Required)

How Long?(Required)

Pharmacy(Required)

Phone(Required)

In case of Emergency who to contact:

Name(Required)

Phone(Required)

Please list Primary Physician(s) contact information:

Physician/Facility(Required)

Phone(Required)

Please list medical concerns in order of importance (chief complaint #1):(Required)

Medical History: Please check all that apply(Required)

Arthritis

Allergies (Hay fever)

Asthma

Alcoholism

Blood Pressure

Bronchitis

Cancer

Chronic Fatigue Syndrome

Carpal Tunnel Syndrome

Cholesterol-Elevated

Circulatory Problems

Colitis

Dental Problems

Depression

Diabetes

Diverticular Disease

Emphysema

Eyes, Ears, Nose Throat

Environmental Sensitivities

Fibromyalgia

Gastroesophageal Reflux

Glaucoma

Gout Heart Disease

Infection, Chronic

Inflammatory Bowel Disease

Irritable Bowel Syndrome

Kidney or Bladder Disease

Liver or Gallbladder Disease

Migraine Headaches

Neurological Problems

Sinus Problems

Stroke

Obesity

Osteoporosis

Sexually Transmitted Disease

Seasonal Affective Disorder

Skin Problems

Ulcer

Urinary Tract Infections

Varicose Veins

Thyroid

Other

Operations: Please include year of operation

Appendectomy(Required)

Yes

Appendectomy Year?

Tonsillectomy(Required)

Yes

Tonsillectomy Year?

Prostate(Required)

Yes

Prostate Year?

Hysterectomy (partial or total)(Required)

Yes

Hysterectomy (partial or total) Year?

Cholecystectomy(Required)

Yes

Cholecystectomy Year?

Other(Required)

Yes

Other Year?

Preventative Care:

Annual Physical

Yes

Annual Physical Year?

Mammogram

Yes

Mammogram Year?

Colonoscopy

Yes

Colonoscopy Year?

Bone Density Scan

Yes

Bone Density Scan Year?

Prostate Exam

Yes

Prostate Exam Year?

Labs

Yes

Labs Year?

Pap Smear

Yes

Pap Smear Year?

Last Menstrual Period

Yes

Last Menstrual Period Year?

Other

Yes

Other Year?

Allergies (please list): Please include reaction

Please list contact information for any physician(s) or facilities that have treated you for the condition that you are seeking treatment for (if applicable)…

Physican/Facility:

Phone

Physican/Facility:

Phone

PHYSICAL HISTORY: PLEASE CHECK ALL THAT APPLY.

Head

Headaches-one sided

Confusion, Brain Fog

Blurred Vision

Headaches-involves back of neck

Dizziness, Unsteadiness

Headaches-associated with light sensitivity

Headaches-interfere with work

Change in memory

Other

Ears

Hearing Loss

Drainage

Ringing/Roaring

Pain

Other

Eyes

Itching

Glaucoma

Sensitive to light

Dryness

Cataracts

Corrective Lenses

Puffy under eyes

Dark circles

Other

Nose

Itches

Runs

Blood streaked mucous

Sneeze

Requires nose drops/spray

No sense of smell

Sinus infection

Other

Mouth and Throat

Snore

Wears dentures

Neck glands swell

Bad breath

Hoarseness

Difficulty swallowing

Sore throats

Grind teeth in sleep

Other

Cardiac and Respiratory

Wheeze

Rapid heart beats

Non-productive cough

Ankle swelling

Bronchitis

Chest pains

Skipped beats

Short of breath

Murmur

Productive cough

Cough up blood

Night sweat

Other

Gastrointestinal/Digestion:

Heartburn

Cramping

Stomach aches

Rectal bleeding

Belching frequently

Indigestion

Mucous in stool

Anal pain

Diarrhea

Blood in stool

Nausea/Vomiting

Bloating

Excess gas

Constipated

Other

Urinary and Genitalia:

Frequent urination

Kidney stones

Yeast infection

Unsatisfactory sexual relations

Painful urination

Weak stream

Difficulty starting urination

Burning

Pass blood

Genital herpes

Lumps, pain swelling testicles

Vaginal Dryness

Painful Intercourse

Irregular Bleeding

Other

Endocrine:

Fatigue

Heat intolerance

Crave sugar

Reaction time slowed down

Feel puffy or swollen all over your body

Sleepiness in the afternoon

Light headed upon standing

Difficult getting out of bed

Deepening of voice

Cold intolerance

Crave salt

Catch colds or infections easily

Decreased libido

Weight gain for no apparent reason

Feel cold, chilled-hands, feet all over for no apparent reason

Musculoskeletal:

Muscle weakness

Morning stiffness

Back pain

Numbness/tingling of hands and feet

Muscle cramps

Joint swelling, pain or stiffness

Increased redness, warmth of joint

Decreased strength

Muscle twitching

Parts of the body feel tender, sore, sensitive to touch

Other

Skin:

Eczema

Easy bruising

Brittle nails

Hives

Dry skin

Rash

Oily

Other

Psychological:

Often unhappy

Difficulty falling asleep

Misunderstood by others

Unable to concentrate

Use tranquilizers

Considered a nervous person

Easily flare in anger

Frequently keyed up and jittery

Am a workaholic

Extremely shy or sensitive

Difficulty staying awake

Other

Physical History:

Please list any prescription medications, OTCs (over the counter medications), vitamins, minerals, supplements you are taking. Please list the amounts (i.e. 500 mg tablet 2x/day), when you take them (schedule) and why you are taking them.

Social History:

Children(Required)

Yes

How Many?

Cigarretes(Required)

Yes

How much /day? How many years?

Cigars(Required)

Yes

How many /day? week?

Chewing Tobacco(Required)

Yes

How many /day? week?

Alcohol(Required)

Yes

How many /day? week?

Coffee(Required)

Yes

How many /day? week?

PMI/FH: HAVE YOUR FAMILY MEMBERS HAD ANY OF THE PROBLEMS LISTED BELOW?

Alcoholism

Yes

Who among the family members?

Anemia

Yes

Who among the family members?

Arthritis

Yes

Who among the family members?

Asthma

Yes

Who among the family members?

Cancer

Yes

Who among the family members?

Diabetes

Yes

Who among the family members?

Emphysema

Yes

Who among the family members?

Heart Disease

Yes

Who among the family members?

High Blood Pressure

Yes

Who among the family members?

Osteoporosis

Yes

Who among the family members?

Mental Illness

Yes

Who among the family members?

Thyroid Disorders

Yes

Who among the family members?

Other

READ THOROUGHLY BEFORE SUBMITTING

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I hereby acknowledge receipt of the Notice of Privacy Practices for KC Wellness Center regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting KC Wellness Center, 1412 NW Vivion Road Kansas City, MO 64118.

CONSENT TO TREAT

I hereby authorize the Doctor’s to treat my case as they deem appropriate.

Name(Required)

First Middle Last

Date(Required)

Month

Day

Year

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