MCN intake form 11/10
www.minneapolisclinic.com
HEALTH AND HISTORY FORM Thank you for filling out this form. The information you provide will facili...
HEALTH AND HISTORY FORM Thank you for filling out this form. The information you provide will facilitate your visit and will be entered into your medical record. Please use either a black or blue ball point pen to fill out the form. MCN Provider:___________________________
Your Name:______________________________________ Date of birth:________________ Age: _________ Height:__________ Weight:__________ Date of visit:_________________ Handedness (with which hand do you write, or throw a ball, for e.g.): Right / Left / Either Name of the doctor who referred you to our clinic:_________________________________ Briefly list the reason(s) for this visit: ____________________________________________________________________________ ____________________________________________________________________________ Medical History: Please indicate if you currently have, or have had in the past, any of the following: CONDITION Anxiety Asthma Black Outs Blood Clots Cancer Depression Diabetes Emphysema Head Injury
Any other condition(s) not listed above: ____________________________________________
Past Surgical History: Please list any surgeries you have had: SURGERY
APPROXIMATE DATE
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Allergies: Please list any allergies or reactions you have had to drugs: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
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MCN intake form 11/10
Personal History:
Yes. How many packs a day?______ How many years have you smoked?_____ Do you smoke? No. Have you ever smoked ? Y / N. If "Yes", when did you quit?_____________
Do you drink alcohol? Y / N
Approximate daily or weekly amount: _____________________
Daily caffeine consumption (cups of coffee or cola, for e.g.)?____________________________
Have you ever been on disability? Y / N ___________________________________________
Do you use street drugs? Y / N __________________________________________________
Have you ever been treated for chemical dependency? Y / N ___________________________ Marital Status: Married
Single
Divorced
Widowed/Widower
Domestic Partner
If you have children, how many?_____________________________________ Occupation:____________________________________________________ Education: Please list highest school grade attended ____________________
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MCN intake form 11/10
FAMILY HISTORY Yes. Age?________ Present state of health:______________________ Father: Alive? No. Age at death?________ Cause of death:______________________
Yes. Age?________ Present state of health:______________________ Mother: Alive? No. Age at death?________ Cause of death:______________________
Yes. Age?________ Present state of health:______________________ Spouse: Alive? No. Age at death?________ Cause of death:______________________
YOUR CURRENT MEDICATION LIST: Name of prescription or over-thecounter medication
Strength (How many mg?)
How many pills do you take daily?
Please tell us about the Pharmacy where you usually fill your prescriptions. This information may allow us to send prescription and refill information electronically to your pharmacy.
Pharmacy Name:_________________________________ Tel. number:___________________ Street address________________________________________________________________ City:____________________________ State:__________________ Zip:__________________
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MCN intake form 11/10
Please indicate if you have any of the following symptoms:
Stomach/Intestinal/Abdominal Discomfort
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Bowel problems
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Balance problems
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Dizziness
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Co-ordination problems
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Weakness/Paralysis
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Chest Pain
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Hearing loss
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Ringing in Ears
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Vision problems
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Memory difficulty
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Numbness/Tingling
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Neck Pain
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Back Pain
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Joint Pain
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Arm/Leg Pain
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Restless Legs
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Movement/Tremor
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Speech Difficulty
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Swallowing
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Shortness of breath
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Weight Gain or Loss
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Skin Changes/Rash
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Depression
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Anxiety
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Impotence
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Bladder problems
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Speech difficulty
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Swallowing difficulty
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Snoring
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Insomnia
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Unusual Behaviors/Symptoms During Sleep □ Pain in legs when you walk
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MCN intake form 11/10
Please give us the following information if you have had any of these tests: Test
