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Patient Intake Form
Patient Full Name
Section 3: Medical History
Please check all that apply
3.1) Cental Nervous System
Pain
Migraines/Headaches
Seizures
Stroke
Sleep concerns
3.3) Respiratory
Chronic Disease
Chronic Cough
Shortness of Breath with exertion
Shortness of Breath minimal activity
Shortness of Breath at rest
Home Oxygen
Obstructive Sleep Apnea
3.5) Dietary & Dental
Difficulty Swallowing
Lactose Intolerance
Gluten Intolerance
Vegan/Vegetarian
Use of Meal Support Services
Upper Dentures
Lower Dentures
3.7) Skin
Open Wounds
Skin Breakdown Risk
Eczema
Psoriasis
Acne
3.2) Cardiovascular
Hgh Blood Pressure
Low Blood Pressure
Heart Attack
High Cholesterol
Edema
Atrial Fibrillation
3.4) Gastrointestinal
Heartburn/Acid Reflux
Indigestion
Diverticulosis/Chronic Colitis
Hernia
Constipation
Diarreha
3.6) Urinary & Liver
Hepatitis
Kidney Concerns
Bladder Infections
Voiding Concerns
3.8) Mental/Social Support
Anxiety
Depression
Eating Dissorder
Schizophrenia
Recreational Drug Use
3.9) Mobility/Gait
Move Independently
Balance Concerns
Cane/Walker/Wheelchair
Glasses
Hearing Aids
Arthritis/Osteoperosis
Prosthesis
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