INTAKE FORM - Valeria Lieveld

Please complete this intake form below. That prevents a lot of misunderstandings.
Thanks in advance for the effort.

Intake (EN) (#3)

Surname:

Name:

Date of Birth:

Address:

City:

Postcode:

Phone number:

Gender:

Insurance Company:

Home doctor:

Email:

Diagnosis:

Disease history:

Please answer the questions below in as much detail as possible.

What are your current complaints?

When did the complaints start?

Did you have any injuries/traumas (accidents, concussions, etc.)?

Did you have any surgeries (no matter how long ago)?

Did you have any inflammations and/or infections in the past (internal organs, joints, etc.)?

Do you use any medications? If so, which ones?

Are you pregnant or breastfeeding?

What kind of work do you have?

Have any important events happened in your life? (relocation, divorce, etc.) In particular, look for events from six months to a year before the start or increase in the number of complaints.

Have you received any other treatment for these complaints?

Have you received professional medical help with these complaints (X-ray, NMRI scan, etc.)?

Write down, please, what diseases and complaints did you have or still have?

Heart and/or blood vessels (e.g., heart disease, vascular disease, heart palpitations, high or low blood pressure):

Respiratory organs (e.g., allergic conditions, chronic bronchitis, asthma, pleurisy):

Blood (e.g., blood disease, jaundice (hepatitis A or B)):

Brain and spinal cord (e.g., dizziness, convulsions, chronic headache, stroke, back paralysis, rheumatism):

Bones (e.g., joint complaints, sciatica, back complaints, scoliosis, kyphosis, feet complaints, tendency to fracture, osteoporosis):

Digestive organs (e.g., complaints from the gastrointestinal tract, gallstones, inflammation of the gallbladder, inflammation of the colon):

Urinary system (e.g., kidney stones, kidney disease, inflammation or disease of the urinary tract):

Eyes and ears (e.g., inflammation, anomalies, otitis media, deafness, noises):

Genitals (e.g., complaints of pain in the uterus, ovaries, menstrual pain, fibroids, prostate):

Metabolism (e.g., thyroid disorders, diabetes. Body weight: deviations from normal weight, eating disorders such as anorexia, bulimia. Infectious diseases or infectious skin diseases):

Other diseases (including autoimmune diseases), ailments or complaints, cancer:

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