top of page

Dr. Justin Fortier

Intake Form

Please complete and submit. Thank you!

First Name

Last Name

Date of Birth

Email

Gender

Male

Female

How did your hear about me?

Describe to me in as many words as you’d like your current condition that your seeking help with.

How long have you experienced this?

What would be your goal in treatment?

Are you willing to make dietary adjustments as needed to resolve it? Do you have dietary restrictions?

Health History

List Current Other Health Issues and Problems

List Other Practitioners Seen, treatments, Self-Care Activities, and Results

List Of Surgeries You Have Had With Dates

List illnesses You Have Ever Had Previously If Any

List All Medications, Vitamins, Herbs, And Other Supplements You are taking, the dose, the reason for taking

List all medications and other substances (foods) to which you are allergic

Ever Been In An Accident Or Seriously Injured

Do You Have Dental Or TMJ Problems

Family History

Please list age(s) and health problems (if any); if deceased, please list age at death and cause of death: Father Mother Children Grandparents Brothers Sisters

General

Describe use of Tobacco Alcohol Other Drugs

Exercise Habits/ Physical Activity

How Many hours per night do you sleep? Do you fall right asleep?

Do you snore?

Yes

No

Sometimes

Do you remember your dreams?

Yes

No

Sometimes

Do you grind your teeth?

Yes

No

Sometimes

Do you have nightmares?

Yes

No

Sometimes

Do you have restless legs (RLS)?

Yes

No

Sometimes

Do you have night sweats?

Yes

No

Sometimes

Have you had any labs done recently? If yes, please attach or send to me

Yes

No

Diet History

How Much do you drink each day: water juice soda diet, soda regular Coffee regular or decaf tea sweet energy Drinks

List Oils/Fats you are cooking with

Do you use butter, margarine, shortening, or coconut oil

Do you skip meals

Are you on any special diet or nutrition program

What foods do you dislike

What are your favorite foods

Are you allergic or sensitive to any foods If yes, name the food and describe

What foods do you crave: Meats, Fats, Sweets, Salty, Spicy, Sour, Cereals, Dairy, Vegetables, Fruits, Breads, Fatty Foods

Do you eat organic foods

Do you eat from fast food restaurants if yes how often

What do you eat for breakfast

What do you eat for lunch

What do you eat for dinner

What do you eat for snacks

What foods do you eat a lot of (at least once a day, every day)

How many bowel movements do you have per day

Pain Questionnaire

Do you get Aches, Pins & Needles, Burning, Stabbing, Numbness, Throbbing, Other? Where do you feel it? When do you feel it?

Symptom Survey

Check the symptom(s) if you are currently experiencing it, common occurrence, or have in the last 3 months

General

Low energy-fatigue

Weakness

Fever-chills

Headaches

Lack of sleep

Reduced mental acuity

Mouth/Throat

Bleeding gums

Tooth decay

Frequent sore throats

Grind teeth at night

Hoarse voice/loss of voice

Ears

Ear discharge/excessive wax

Earaches or infections

Hearing loss

Ringing tinnitus

Vertigo dizziness

Eyes

Cataracts/Glaucoma

Eye pain

Double vision

Far or near sightedness

Flashing lights

Spots specks or floaters

Nose/Sinus

Sinus Congestion

Frequent Colds/Infections

Nosebleeds

Neck

Goiter

Lumps

Pain/stiffness

Swollen Glands

Skin

Dry skin

Itching

Varicose veins

Cold or canker sores/fever blisters

Boils

Hives

Rashes

Sores

Change in your skin/nails

Urinary

Frequent urination

Blood in urine

Incontinence

Painful urination

Urinate more than once at night

Muscles & Joints

Arthritis

Tendonitis

Bursitis

Gout

Poor posture

Chronic pan

Pain with specific movement

Pain relieved with anti-inflammatory drugs (aspirin ibuprofen..)

Pain tenderness or numbness in:

Neck shoulders arms elbows wrist/hands upper back lower back hips knees feet/ankles

Respiratory

Asthma

Bronchitis

Cough

Pneumonia

Tend to hold breath

Wheezing

Sputum

Trouble breathing with exercise

Neurologic

Blackouts

Fainting

Numbness

Paralysis

Dizziness

Tremors

Seizures

Gastrointestinal

Belching flatulence/gas

Black or tarry stool

Change in stool

Colitis

Constipation

Diarrhea

Distension

Excessive hunger

Heartburn

Food intolerance

Hemorrhoids

Indigestion

Poor appetite

Trouble swallowing

Vomiting

Hematologic

Anemia

Bruise easily

Psychological

Anxiety

Depression

Insomnia/ hard to sleep

Nervousness

Poor memory

Forget quickly

Violent thoughts

Suicidal thoughts

Tend to worry

Endocrine

Diabetes

Excessive thirst or hunger

Excessive sweating

Lack of sweating

Heat or cold intolerance

Thyroid problem

Hair loss

Dizzy when standing up/rising quickly

Excessive weight gain

Excessive weight loss

Cardiac/Vascular

Arrythmia

Chest pain

Heart trouble

Murmur

High blood pressure

Palpitations

Shortness of breath

Swollen feet or lower legs

Racing or pounding heart

Blood clots

Leg cramps

Poor circulation

Sexual/Hormonal

Prostate problems

Hernia

Erection trouble

Discharge

Premature ejaculation

STD

Itching/rashes

For Females:

Sexual/Hormonal

Bleeding between periods

Decrease sexual interest

Pain with intercourse

Discharge

Itching

Sores

Yeast infections

STD’s

PMS

Breast tenderness

Cramping bloating

Back Pain

Over-emotional

Tired/fatigue

Number of days in cycle

Number of pregnancies

Usual length of period

Number of deliveries

Birth control method

Other Pain

Child form difference

Is he or she on a specific diet or nutrition program list

YES

NO

If "yes" please describe

Is he or she on a specific diet or nutrition program list List the diets you have tried in the past with results please list all lab work your child has done and include a copy

Is there anything else you would like to tell me or feel I should know

Thanks for submitting!

Phone/Address

972-839-9926

4961 Long Prairie Rd suite 130

Flower Mound, TX 75028

Email

Fortierchiro@gmail.com

Follow Me

© 2022 By Justin Fortier.
Proudly created with Wix.com

bottom of page