The Tahki Institute

Patient Intake Form

The Tahki Institute will never use or share information for any other purpose than consultation

Personal & Contact Information

Name:

Date of birth:

Address:

Status:

Sex:

Mobile number:

Home Phone:

SSN:

Email:

Employer:

Employer Phone number:

Emergency Contact Information

Emergency Contact Person:

Relationship:

Phone number:

Past Medical and Surgical History

Please indicate whether you or your relatives have been diagnosed with any of the following diseases or symptoms (specify which relative and the date of diagnosis). *Relatives include parents, grandparents, siblings.

Diabetes (Specify: Type 1, II, Prediabetes, Gestational Diabetes) High Cholesterol High blood pressure Sleep apnea Thyroid disease (hypo or hyperthyroid) Others (describe)

Other medical / surgical history details

Injuries

Describe / specify	Age
Back injury
Head injury
Neck injury
Other (describe)

Diagnostic Studies & Operations

Describe / specify	Date
CAT Scan: Abdominal, brain, Spine
Chest X-ray
Colonoscopy
EKG
Mammogram

Operation	Age at Operation
Gallbladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)

Family Health History

Please complete the following information concerning your family's health history:

Relative	If Living (Health & Age)	If Deceased (Age at Death & Cause)
Father
Mother
Siblings
Spouse / Partner
Children

Medical Symptoms Questionnaire

Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having recent or somewhat severe health symptoms, please indicate that you will fill out the questions for the past 48 hours.

Timeframe: Past 30 days Past 48 hours

Medication, Supplement, and Antibiotic Intake

Medication / Supplement / Antibiotic	Dose	Units	Frequency	Start date	Stop date

Are you allergic to any medications? Yes No

If Yes, please list:

Antibiotic Usage

Please indicate how often you have taken antibiotics during each life stage:

Life Stage	< 5 times	> 5 times
Infancy / Childhood
Teen
Adulthood

Lifestyle & Nutrition

Physical Activity

Activity	Type / Intensity	# days per week	Duration (minutes)
Stretching / Yoga
Cardio / Aerobics
Strength-training
Sports or Leisure
Other (Specify / Describe)

Does anything limit you from being physically active? Yes No

Stress & Habits

Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high):

Work

Financial

Family

Health

Social

Other

What helps you to unwind?

Do you smoke? Never In the past Currently

Type/amount/frequency

Weight History

Would you like to be weighed today? Yes No

Height

Current Weight

Desired Body Weight

Highest Adult Weight

When?

Weight 1 year ago

Have you had any recent changes in your weight that you are concerned about?

Digestive History & Intake Information

Do you associate any digestive symptoms with eating certain foods? Please explain:

How often do you have a bowel movement?

If you take laxatives, what type / brand and how often?

If you follow a special diet / nutritional program, check the following that apply:

Which meals do you eat regularly, check all that apply:

Breakfast Lunch Dinner/Supper Snack (time)

Beverage Intake

Beverage Type	Daily Amount	Weekly Amount	Monthly Amount
Water: Tap, Filtered, Bottled
Coffee: Reg, Decaf, Latte
Tea: what type?
Juice: Natural, Fruit Drinks
Soda: Diet, Regular
Milk: Whole, 2%, 1%, Skim, Alt
Alcohol: Wine, Beer, Liquor
Others:

Goals and Readiness Assessment

My overall health goals are:

If I could change three things about my health and nutritional habits, they would be:

The biggest challenge(s) to reaching my nutrition goals is/are:

On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:

To improve your health, how ready / willing are you to...	1	2	3	4	5
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle: (ex: work demands, sleep habits, physical activity)
Practice relaxation techniques
Engage in regular exercise / physical activity
Have periodic lab tests to assess your progress

Sleep Assessment

Sleep Pattern

Typical bedtime: Weekday

Typical bedtime: Weekend

Typical awakening time: Weekday

Typical awakening time: Weekend

Typical hours in bed:

Typical hours of sleep:

Typical amount of time it takes to fall asleep:

Typical number of awakening per night:

My sleep pattern is irregular Yes No I awaken early in the morning still tired but unable to return to sleep Yes No

Sleep Environment & Habits

Breathing & Daytime Sleepiness

Insomnia & Miscellaneous

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
0 = would never doze | 1 = slight chance of dozing | 2 = moderate chance of dozing | 3 = high chance of dozing

Situation	Chance of dozing (0-3)
Sitting and reading
Watching TV
Sitting, inactive in a public place
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
TOTAL (Range of 0-24)