Female Patient Intake Form

Female Patient Intake Form

Chiropractic & Functional Health Assessment

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Part I: Chief Health Concerns

Please list your 5 major health concerns in order of importance:

1
2
3
4
5

Part II: Symptom Assessment

Instructions: Please select the appropriate number for all questions below:
0 = Least/Never | 1 = Occasionally | 2 = Frequently | 3 = Most/Always

Category I

Feeling that bowels do not empty completely
0
1
2
3
Lower abdominal pain relieved by passing stool or gas
0
1
2
3
Alternating constipation and diarrhea
0
1
2
3
Diarrhea
0
1
2
3
Constipation
0
1
2
3
Hard, dry, or small stool
0
1
2
3
Coated tongue or "fuzzy" debris on tongue
0
1
2
3
Pass large amount of foul-smelling gas
0
1
2
3
More than 3 bowel movements daily
0
1
2
3
Use laxatives frequently
0
1
2
3

Category II

Increasing frequency of food reactions
0
1
2
3
Unpredictable food reactions
0
1
2
3
Aches, pains, and swelling throughout the body
0
1
2
3
Unpredictable abdominal swelling
0
1
2
3
Frequent bloating and distention after eating
0
1
2
3
Abdominal intolerance to sugars and starches
0
1
2
3

Category III

Intolerance to smells
0
1
2
3
Intolerance to jewelry
0
1
2
3
Intolerance to shampoo, lotion, detergents, etc.
0
1
2
3
Multiple smell and chemical sensitivities
0
1
2
3
Constant skin outbreaks
0
1
2
3

Category IV

Excessive belching, burping, or bloating
0
1
2
3
Gas immediately following a meal
0
1
2
3
Offensive breath
0
1
2
3
Difficult bowel movement
0
1
2
3
Sense of fullness during and after meals
0
1
2
3
Difficulty digesting fruits and vegetables; undigested food in stools
0
1
2
3

Category V

Stomach pain, burning, or aching 1-4 hours after eating
0
1
2
3
Use antacids
0
1
2
3
Feel hungry an hour or two after eating
0
1
2
3
Heartburn when lying down or bending forward
0
1
2
3
Temporary relief by using antacids, food, milk, or carbonated beverages
0
1
2
3
Digestive problems subside with rest and relaxation
0
1
2
3
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
0
1
2
3

Category VI

Roughage and fiber cause constipation
0
1
2
3
Indigestion and fullness last 2-4 hours after eating
0
1
2
3
Pain, tenderness, soreness on left side under rib cage
0
1
2
3
Excessive passage of gas
0
1
2
3
Nausea and/or vomiting
0
1
2
3
Stool undigested, foul smelling, mucous like, greasy, or poorly formed
0
1
2
3
Frequent urination
0
1
2
3
Increased thirst and appetite
0
1
2
3

Category VII

Greasy or high-fat foods cause distress
0
1
2
3
Lower bowel gas and/or bloating several hours after eating
0
1
2
3
Bitter metallic taste in mouth, especially in the morning
0
1
2
3
Burpy, fishy taste after consuming fish oils
0
1
2
3
Difficulty losing weight
0
1
2
3
Unexplained itchy skin
0
1
2
3
Yellowish cast to eyes
0
1
2
3
Stool color alternates from clay colored to normal brown
0
1
2
3
Reddened skin, especially palms
0
1
2
3
Dry or flaky skin and/or hair
0
1
2
3
History of gallbladder attacks or stones
0
1
2
3

Category VIII

Acne and unhealthy skin
0
1
2
3
Excessive hair loss
0
1
2
3
Overall sense of bloating
0
1
2
3
Bodily swelling for no reason
0
1
2
3
Hormone imbalances
0
1
2
3
Weight gain
0
1
2
3
Poor bowel function
0
1
2
3
Excessively foul-smelling sweat
0
1
2
3

Category IX

Crave sweets during the day
0
1
2
3
Irritable if meals are missed
0
1
2
3
Depend on coffee to keep going/get started
0
1
2
3
Get light-headed if meals are missed
0
1
2
3
Eating relieves fatigue
0
1
2
3
Feel shaky, jittery, or have tremors
0
1
2
3
Agitated, easily upset, nervous
0
1
2
3
Poor memory/forgetful
0
1
2
3
Blurred vision
0
1
2
3

Category X

Fatigue after meals
0
1
2
3
Crave sweets during the day
0
1
2
3
Eating sweets does not relieve cravings for sugar
0
1
2
3
Must have sweets after meals
0
1
2
3
Waist girth is equal or larger than hip girth
0
1
2
3
Frequent urination
0
1
2
3
Increased thirst and appetite
0
1
2
3
Difficulty losing weight
0
1
2
3

Category XI

Cannot stay asleep
0
1
2
3
Crave salt
0
1
2
3
Slow starter in the morning
0
1
2
3
Afternoon fatigue
0
1
2
3
Dizziness when standing up quickly
0
1
2
3
Afternoon headaches
0
1
2
3
Headaches with exertion or stress
0
1
2
3
Weak nails
0
1
2
3

Category XII

Cannot fall asleep
0
1
2
3
Perspire easily
0
1
2
3
Under high amount of stress
0
1
2
3
Weight gain when under stress
0
1
2
3
Wake up tired even after 6 or more hours of sleep
0
1
2
3
Excessive perspiration or perspiration with little or no activity
0
1
2
3

Category XIII

Edema and swelling in ankles and wrists
0
1
2
3
Muscle cramping
0
1
2
3
Poor muscle endurance
0
1
2
3
Frequent urination
0
1
2
3
Frequent thirst
0
1
2
3
Crave salt
0
1
2
3
Abnormal sweating from minimal activity
0
1
2
3
Alteration in bowel regularity
0
1
2
3
Inability to hold breath for long periods
0
1
2
3
Shallow, rapid breathing
0
1
2
3

Category XIV

Tired/sluggish
0
1
2
3
Feel cold—hands, feet, all over
0
1
2
3
Require excessive amounts of sleep to function properly
0
1
2
3
Increase in weight even with low-calorie diet
0
1
2
3
Gain weight easily
0
1
2
3
Difficult, infrequent bowel movements
0
1
2
3
Depression/lack of motivation
0
1
2
3
Morning headaches that wear off as the day progresses
0
1
2
3
Outer third of eyebrow thins
0
1
2
3
Thinning of hair on scalp, face, or genitals, or excessive hair loss
0
1
2
3
Dryness of skin and/or scalp
0
1
2
3
Mental sluggishness
0
1
2
3

Category XV

Heart palpitations
0
1
2
3
Inward trembling
0
1
2
3
Increased pulse even at rest
0
1
2
3
Nervous and emotional
0
1
2
3
Insomnia
0
1
2
3
Night sweats
0
1
2
3
Difficulty gaining weight
0
1
2
3

Category XVI

Diminished sex drive
0
1
2
3
Increased ability to eat sugars without symptoms
0
1
2
3
Vaginal dryness
0
1
2
3
Painful intercourse
0
1
2
3
Hot flashes
0
1
2
3
Night sweats
0
1
2
3
Depression or mood swings
0
1
2
3

Category XVII

Increased sex drive
0
1
2
3
Tolerance to sugars reduced
0
1
2
3
"Splitting" type headaches
0
1
2
3
Breast tenderness or fibrocystic breasts
0
1
2
3
Weight gain, especially in hips and thighs
0
1
2
3
Water retention and bloating
0
1
2
3

Category XVIII

Irregular menstrual cycles
0
1
2
3
Anxiety or panic attacks
0
1
2
3
Difficulty sleeping/insomnia
0
1
2
3
Heavy menstrual flow
0
1
2
3
Mood swings or irritability
0
1
2
3
Cyclic headaches or migraines
0
1
2
3

Category XIX

Premenstrual syndrome (PMS) symptoms
0
1
2
3
Painful menstrual cramps
0
1
2
3
Menstrual flow with clots
0
1
2
3
Food cravings before or during period
0
1
2
3
Breast tenderness before period
0
1
2
3
Emotional sensitivity or crying spells before period
0
1
2
3
Acne breakouts around period
0
1
2
3
Bloating before or during period
0
1
2
3

Part III: Lifestyle Assessment

Part IV: Current Medications & Supplements

Part V: Patient Information & Health History

Personal Information

Chief Complaint

Reproductive Health History

Medical History

Let's get started!

Request a date and time that works for your schedule.

Your new patient appointment will include a comprehensive exam, consult with the doctors, and a personalized health plan for addressing your most important health goals.

Office: 4343 West Henderson Blvd, Tampa FL 33629

Call (813) 254-5200

Facebook: https://www.parkerhealing.com

Copyright 2026 . All rights reserved

Office:

4343 West Henderson Blvd, Tampa FL 33629

Call

(813) 254-5200

Facebook:

facebook.com/ParkerNaturalHealthSolutions

Copyright 2026 . All rights reserved. Terms, Conditions, Privacy