SPIRIT OF HEALTH

NEW PATIENT INFORMATION FORM

Name _________________________________________ Date_______________________
Address ________________________________________ Apt.#______________________
City______________________________ State________ ZIP________________________
Home Phone (____) ____-_________ Work Phone (____) ____-______________________
e-mail address: ______________________________________________________________
Referred By:_________________________________________________________________
Occupation _____________________ Employer___________________________________
Date of Birth ______________ Age ____ Sex: M/F Height _____ Weight ____________
Overall health (circle one): Excellent / Good / Fair / Poor / Other:________________________
Chief complaint (reason you are here): (use separate sheet if more room needed)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Previous treatments for this complaint_____________________________________________
___________________________________________________________________________
Other complaints or problems: (use separate sheet if needed)__________________________
___________________________________________________________________________
___________________________________________________________________________
Current medications/drugs being taken: (use separate sheet if needed)___________________
___________________________________________________________________________
Are you currently under the care of a physician or other health care professionals?
(If yes, please give name and date of last visit):
___________________________________________________________________________
Nutritional supplements you are taking:____________________________________________
___________________________________________________________________________
Do you smoke, drink coffee or alcohol? (if yes indicate how much)
Cigarettes ____________ Coffee_______________ Alcohol_________________________
HISTORY:
List any major illnesses (with approx. dates):________________________________________
___________________________________________________________________________
___________________________________________________________________________
List any surgery or operations with approx. date:_____________________________________
___________________________________________________________________________
Past Accidents or injuries:______________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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Marital Status: S M D W
Name of Spouse___________________________________
Describe health of spouse:____________________ Number of children if any ____________
Name of Child
Age Sex Any physical conditions or concerns?
______________________ ___ M/F ________________________________________
______________________ ___ M/F ________________________________________
______________________ ___ M/F ________________________________________
Any family history of serious illnesses (circle those which apply): Cancer / Diabetes / Heart / Other
_______________________________________________________________________
Any household pets or other animals you or family members are in close contact with:
___________________________________________________________________________
What can we do to make you happier?____________________________________________
___________________________________________________________________________
___________________________________________________________________________

Dietary Intake for 2 days before appointment:

Breakfast:

Breakfast:

Snacks:

Snacks:

Lunch:

Lunch:

Snacks:

Snacks:

Dinner:

Dinner:

Snacks:

Snacks:

Body Assessment

Name:
Enter Today's Date in the First Available Column. Place an X next to any Concerns that apply to you at this time.
Date:
Date:
Date:
Concern

X
Illnesses more than twice a year
Body Odor and/Or Bad Breath
Difficulty Digesting Certain Foods
Less than 3 servings of Fruits and Veggies Daily
Monthly Female Concerns
Recent or Frequent use of Antibiotics
Regular Consumption of Alcohol
Gum Problems or Redness on Nose
Food Allergies
Puffiness under Eyes
Smoking
Poor Concentration or Memory
Heavy Coating on Tongue
Belching or Gas After Meals
Stressful Lifestyle
Skin/Complexion Problems
Cravings for Sweets or Junk Food
Daily Consumption of Dairy Products
Feeling Down, Uninterested or Moody
Difficulty Getting to Sleep, Lack of Sleep
Menopausal Concerns
Frequent Urination or Urinary Concerns
Age Related Health Problems
Sore or Painful Joints
Difficulty Maintaining Ideal Weight
Lack of Energy or Endurance
Diet High in Meat and Grains
Heavy Mucus Production or Feeling Congested
Fewer Than Two Bowel Movements per Day
Weak Knees, Ancels or Back
Low Sex Drive
Brittle or Easily Broken Fingernails
Dry, Damaged or Dull Hair
Daily Consumption of Fried Foods
Frequent Feeling Fearful or Timid
Cold hands and Feet
Muscle Cramps or Spasms
Exposure to Air Pollution Daily
Daily Consumption of Caffeinated Beverages
Shallow or Difficulty Breathing, Respiratory Concerns
Restless Sleep or Waking Up Frequently
Recurrent Yeast or Fungal Infections
Weak Bones, Teeth or Cartilage
Feeling Anxious or Worried
Feeling Iritable or Easily Angered
Don't Exercise Regularly

th

9341 W 75 St

Spirit of Health
Overland Park, KS 66204

Phone 913-901-0277

PERMISSION & AUTHORIZATION FORM

PLEASE READ BEFORE SIGNING:
I specifically authorize the natural health practitioners at Spirit of Health to perform a health
analysis and to develop a natural, complementary health improvement program for me which may
include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health,
and not for the treatment, or "cure" of any disease.
I understand that this analysis involves testing that is a safe, non-invasive, and natural way of
analyzing the body's physical and nutritional needs, and that deficiencies or imbalance in these areas
could cause or contribute to various health problems.
I understand that this analysis is not a method for "diagnosing" or "treating" of any disease
including conditions of cancer, AIDS, Infections, or other medical conditions, and that these are not
being tested for or treated.
No promise or guarantee has been made regarding the results of this analysis & testing or any
natural health, nutritional or dietary programs recommended, but rather I understand that this is a
means by which safe natural programs can be developed for the purpose of bringing about a more
optimum state of health.
I have read and understand the foregoing.
This permission form applies to subsequent visits and consultations.
Date: ________________
Print Name: ________________________________
Address: ___________________________________
City _________________

State ___ Zip ________

Phone: (____) _____ - ____________

Signed: ____________________________________
(If minor, signature of parent or guardian required)