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Dr. Anca's Protocol for immune support-kids
Only $10.00
Dr. Anca's Protocol for weight loss
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Dr. Anca's cold and flu Prevention Protocol=Homeopathic "flu-shot"
Only $10.00

Early detection-Glucose Test
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Dr. Anca's Protocol for Depression
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Untitled Document
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Please note: Our ability to draw effective conclusion about your present state of health and the best way to improve it depends, to certain extents, on your ability to complete this questionnaire honestly and accurately. The doctor is the only person who will review this survey and your confidentiality is strictly maintained. If you have questions or concerns about this questionnaire, please call the office at once and we will help you to decide how to best solve the issue.

Please be sensitive to the fact that some people are not able to tolerate the odor of the cigarettes, perfume cologne or after-shave lotions. Please come to our office smoke and fragrance free. We will appreciate your attention to this. Thank you.

In order to make your consultation more efficient, please fill out the Intake Form ahead of time and Send it (if your consultation is Online) or Print it (if your consultation is in the office) and bring it with you at the time of your appointment.

 

Personal Information
First Name:
Last Name:
Address:
Postal Code:
Home Phone:
Business Phone:
Date of Birth:
mm/dd/yyyy
Age:
Height: (cm)
Weight: (pounds)
How did you find out about our office?
Referral: (i.e: Internet, Friend, Referral)
Email:
................................................................................................................................

Please state your primary reason for attending this office. If this involves a specific cpndition, please describe it in detail. In your own words, list the very first time that you noticed this condition and describe carefully any factors that you suspect may have plaued a role in its onset and perpetuation.

Please list every detail and give the doctor the opportunity to distinguish what may not be relevant to your case.

Please list the 5 most significant, stressful events in your life, from the most recent to the most distant. Are any of these situations continuing to impact your life? If so, please indicate these clearly.

A. What would you like to see changed in your health? (indicate how long each of your conditions have existed.

B. How long has it been since you were totally well?

C. How many course of antibiotics have you had in the last 10 years?

Have you had any adverse reactions?

D. Have you had any vaccinations? (Yes or No)

Have you had any adverse reactions?

E. Have you had any silicone implants? (Yes or No)

F. Describe your home/Work sorroundings (Any health hazards e.g. molds, powerlines close by, computer exposure, chemical exposure)


REVIEW OF SYMPTOMS
Please circle “Y” if you have the conditions now and “P” if you have had it in the past. 
Skin  
Rashes:
Yes No had it in the past
Hives:
Yes No had it in the past
Acne:
Yes No had it in the past
Boils:
Yes No had it in the past
Eczema
Yes No had it in the past
Psoriasis
Yes No had it in the past
Dry Skin
Yes No had it in the past
Itching:
Yes No had it in the past
Lumps:
Yes No had it in the past
How Often:
Other:
Eyes  
Double Vision:
Yes No had it in the past
Redness:
Yes No had it in the past
Cataracts:
Yes No had it in the past
Dryness
Yes No had it in the past
Contact Lenses
Yes No had it in the past
Itching
Yes No had it in the past
Blurring
Yes No had it in the past
Tearing:
Yes No had it in the past
Glaucoma:
Yes No had it in the past
Light Sensitive:
Yes No had it in the past
Discharge:
Yes No had it in the past
Pain:
Yes No had it in the past
Impaired Vision
Yes No had it in the past
Dryness:
Yes No had it in the past
Blind Spot(s)
Yes No had it in the past
Other:
Head  
Headaches:
Yes No had it in the past
Migraine
Yes No had it in the past
Dizziness::
Yes No had it in the past
Injuries:
Yes No had it in the past
Other:
Neck  
Pain
Yes No had it in the past
Swollen Glands:
Yes No had it in the past
Stiffness
Yes No had it in the past
Goitre:
Yes No had it in the past
Lumps:
Yes No had it in the past
Other:
Mouth and Throat
Hoarseness:
Yes No had it in the past
Gum Problems:
Yes No had it in the past
Dental Cavities:
Yes No had it in the past
Sores:
Yes No had it in the past
Mouth Dryness:
Yes No had it in the past
Sore Throats
Yes No had it in the past
Lost Taste:
Yes No had it in the past
Other:
Ears
Discharge:
Yes No had it in the past
Itching:
Yes No had it in the past
Excess Wax:
Yes No had it in the past
Infections:
Yes No had it in the past
Ringing:
Yes No had it in the past
Earache:
Yes No had it in the past
Hearing Loss
Yes No had it in the past
Other:
Nose and Sinuses
Bleeding:
Yes No had it in the past
Stuffiness:
Yes No had it in the past
Hayfever:
Yes No had it in the past
Injury:
Yes No had it in the past
Colds:
Yes No had it in the past
Allergies:
Yes No had it in the past
Obstructions:
Yes No had it in the past
Sinus Problems:
Yes No had it in the past
Other:
Breasts
Lumps:
Yes No had it in the past
Tenderness:
Yes No had it in the past
Self Examine?
Yes No had it in the past
Other:
Respiratory
Wheezing:
Yes No had it in the past
Cough:
Yes No had it in the past
Breath Short:
Yes No had it in the past
Difficult Breath:
Yes No had it in the past
Chest Pain:
Yes No had it in the past
Bloody Sputum:
Yes No had it in the past
Emphysema:
Yes No had it in the past
Asthma:
Yes No had it in the past
Breath Painful:
Yes No had it in the past
Bronchitis:
Yes No had it in the past
Pneumonia:
Yes No had it in the past
Pleurisy:
Yes No had it in the past
Last Chest
X-ray:		 Give Date (MM-DD-YYYY)
Last TB Test: Give Date (MM-DD-YYYY)
Other:
Cardiovascular
Heart Disease:
Yes No had it in the past
Angina:
Yes No had it in the past
High Blood Pressure:
Yes No had it in the past
Murmurs:
Yes No had it in the past
Chest Pain:
Yes No had it in the past
Palpitations:
Yes No had it in the past
Ankle Swelling:
Yes No had it in the past
Rheumatic Fever:
Yes No had it in the past
Last ECG Test: Give Date (MM-DD-YYYY)
Other:
Peripheral Vascular
Cold Hands/Feet:
Yes No had it in the past
Deep Leg Pain:
Yes No had it in the past
Varicose Veins:
Yes No had it in the past
Thrombophlebitis:
Yes No had it in the past
Other:
Gastrointestinal
Heartburn:
Yes No had it in the past
Difficult Swallow:
Yes No had it in the past
Thirst Changes:
Yes No had it in the past
Appetite Changes:
Yes No had it in the past
Nausea:
Yes No had it in the past
Indigestion:
Yes No had it in the past
Gas/Belching:
Yes No had it in the past
Constipation:
Yes No had it in the past
Rectal Bleeding:
Yes No had it in the past
Hemorroids:
Yes No had it in the past
Jaundice:
Yes No had it in the past
Hernias:
Yes No had it in the past
Diarrhea:
Yes No had it in the past
Number of BM/Day:
Urinary
Pain Urinating:
Yes No had it in the past
More Frequent:
Yes No had it in the past
Reduced Flow:
Yes No had it in the past
Kdiney Stones:
Yes No had it in the past
Blood in Urine:
Yes No had it in the past
Infections:
Yes No had it in the past
Incontinence:
Yes No had it in the past
Other:
Musculoskeletal
Joint Pains:
Yes No had it in the past
Arthritis:
Yes No had it in the past
Broken Bones:
Yes No had it in the past
Numbness:
Yes No had it in the past
Tingling:
Yes No had it in the past
Muscle Spasms:
Yes No had it in the past