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Home
Patients
- Patient Intake Form
Services
About us
- Testimonials
Contact

Patient Intake Form

Medical History Questionnaire

Please answer these questions to the best of your ability. By doing so you are helping us to find the cause for your health problems as quickly as possible.

General Information
Name
First Last
Birth Date
Place of Birth
Address
Phone number
E-mail address
Occupation
Who referred us to you?
Health-Related Questions
Your concern: what brought you to us?
Do you have an underlying medical disease? Since when and what was the diagnosis?
- Yes
- No
If Yes - Since when and what was the diagnosis?
Acute medical complaints: where and since when?
- Yes
- No
If Yes - Where and since when?
Did you suffer from allergies as a child?
- Yes
- No
Do you snore?
- Yes
- No
Have you ever been diagnosed with a concussion?
- Yes
- No
Have you been in a car accident?
- Yes
- No
Do you have tinnitus?
- Yes
- No
Do you suffer from migraines or headaches?
- Yes
- No
Do you suffer from skin issues?
- Yes
- No
Do you suffer from anxiety?
- Yes
- No
Do you suffer from depression?
- Yes
- No
Do you have thyroid issues?
- Yes
- No
Do have sweaty hands or sweaty feet? If so how often?
- Yes
- No
If Yes - How often do your hands or feet sweat?
Do you have irritated eyes, red, dry, burning, itching or twitching?
- Yes
- No
Are you sensitive to bright lights?
- Yes
- No
Are you sensitive to loud sounds and or vibrations?
- Yes
- No
Are you sensitive to the smell of gas, artificial fragrances or cleaning products?
- Yes
- No
Do you poop less than once a day?
- Yes
- No
Do you have difficulty breathing at night because of nasal congestion?
- Yes
- No
Do you have a nasal self-care routine?
- Yes
- No
Do you have difficulty pressurizing on an airplane?
- Yes
- No
Do you have a dental self-care routine?
- Yes
- No
For women: are you pregnant, and if yes, how many months?
- Yes
- No
Enter Your Pregnancy Month
Nutritional Questions
Do you consume sugar and sugary drinks? If yes, which ones and how often and how much?
- Yes
- No
If Yes - Which ones and how often and how much do you drink?
Do you consume dairy products? If yes, which dairy products do you consume and how often??
- Yes
- No
If Yes - Which ones and how often and how much do you drink?
Do you eat bread or other cereal/grain products?
- Yes
- No
Lifestyle Questions
Do you smoke?
- Yes
- No
Do you drink alcohol?
- Yes
- No
How many hours a day do you spend with digital media? (TV, computer, smartphone, tablet)
Do you use a DECT telephone (cordless) at home or in your work place?
- Yes
- No
Do you make phone calls with your smartphone placed to your ear? If yes, how many minutes a day?
- Yes
- No
How Many Minutes a Day?
How far is the next cell tower from where you sleep? And since when?
Do you turn your Wi-Fi router off at night?
- Yes
- No
Do you have Wi-Fi reception from surrounding buildings or apartments?
- Yes
- No
Do you have and EMF Killswitch in your home?
- Yes
- No
Do you where uv-blue blocking glasses when using technology?
- Yes
- No
Do you exercise and if yes, which types of exercise and how often / how much?
- Yes
- No
Please Specify
How many hours do you sleep on average each night?
What percentage of your waking hours would you categorize as being stressful?
Signature
- I comply with receiving notifications via SMS.
- I nearby confirm my signature that all the information Provided here is truthful and that I will bear all costs of the treatment.
Location
Date*
Signature

Dr. Russell John Kort is an Author, Public Speaker, Resilience Specialist, and the 2019 Innovator of the year for BrainTap Technologies. Dr. Kort is a 1999 graduate of the prestigious Palmer College of Chiropractic in Davenport, Iowa.

SERVICES

Electromagnetic Hypersensitivity
Brain Performance
Hyperbaric Oxygen
Concussion/TBI
Auto Collisions

REACH US

Email
frontdeskk2ph@gmail.com
Phone
(503) 625-5678
Fax
(503) 925-8302
Address
20407 SW Borchers Drive, Suite 201 Sherwood, OR 97140

© Copyright 2019. All rights reserved to muslimhealthinstitute.

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