Whole Health Clinic 6632 S. 191 st Place, Suite E-110; Kent, WA (425) Fax (425)
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1 1 Whole Health Clinic 6632 S. 191 st Place, Suite E-110; Kent, WA (425) Fax (425) Date: Name: Age: Birth Date: Gender: M F Address: City Zip: Phone: Home Can messages be left for you here? Y N Work Can messages be left here? Y N Cell Can messages be left here? Y N Would you like to receive notices from our office? Occupation: Single or Married? Employer: Social Security Number: Name of Emergency Contact: Phone: (H)/(cell) How did you hear about us? Insurance information: Name of the insurance company? Subscriber s name (this could be you or your partner)? Subscriber s employer? Subscriber s date of birth? Present Health Concerns: Please list your most important health concerns in their order of significance. 1.) 4.) 2.) 5.) 3.) 6.) Please list any prescription or over the counter medications that you are currently taking: Name of drug Dose Reason for taking For how long Who prescribed
2 2 Please list any vitamins, minerals, herbs or homeopathic remedies that you are presently taking: Name of supplement Dose Reason for taking For how long Who prescribed Please list your current health care providers: Name Type For what reason Phone (if available) Hospitalizations, Serious Illnesses and Injuries: (Please list reason and dates, excluding non-surgical childbirth) Date of last full physical exam: Results: normal other Date of last blood work: Results: normal other (Females) Are you pregnant, or is there any chance that you are pregnant? Do you have any surgical implants? If so, what type and where in your body? Have you seen a naturopath before? If so, how many other naturopaths have you seen? How long have you been interested in natural medicine? Lifestyle Habits: Tobacco (currently):none Daily Weekly Monthly Amount? Do you any history of smoking? If so, how many years? What years? Coffee: None Daily Weekly Monthly Amount? Black tea: None Daily Weekly Monthly Amount? Soft drinks: None Daily Weekly Monthly Amount? Alcohol: None Daily Weekly Monthly Amount? History of significant alcohol consumption or alcoholism? How long and how much? Recreational drugs: None Daily Weekly Monthly Amount?
3 3 History of significant recreational drug use? Exercise: None Daily Weekly Monthly Amount? Are you currently sexually active? How do you rate your libido on a scale of 0-10 (optional)? Diet: Please describe your typical diet (breakfast, lunch, and dinner), including any guidelines or restrictions that you follow: Breakfast: Lunch: Dinner: Do you have a gas stove or electric stove at home? How often do you eat fish (How many times per week or per month)? Do you have a sweet tooth? Do you chew gum often, and how often? Do you use artificial sweeteners such as Splenda? Which ones? (Optional) Please describe briefly your religious and/or spiritual background/beliefs: SEAM Questions (Sleep, Energy, Appetite, and Mood) Sleep: Hours of sleep per night? Any problems with sleep? How often in a week do you wake up feeling refreshed? Energy: Energy level on a scale of 1-10 (1 is you cannot get up,10 is optimal full energy)? Appetite: How is your appetite on a scale of 0-10? (zero is you have no appetite, 10 is voracious appetite)? Mood: How would you describe your day-to-day mood?
4 4 What is your overall sense of well-being? PATIENT PROFILE (PLEASE ANSWER CAREFULLY.) REVIEW OF SYSTEMS: Y = Now P = Past For the following, PLEASE CIRCLE, or fill in blanks. Y means you have the condition now. P means that you had the condition in the past, but not any more. If you have never had a condition, leave it blank. GENERAL Height Weight Weight changes Y P Night Sweats Y P Fatigue Y P Fever Y P SKIN Acne Y P Eczema Y P Hives Y P Rashes Y P Infection Y P Growths (such as warts) Y P Changes in hair/nails Y P Transdermal skin patches? HEAD Headache Y P Head Injury Y P EYES Dryness Y P Glasses or contacts Y P Eye pain Y P Tearing Y P Double vision Y P EARS Impaired hearing Y P Ringing (tinnitus) Y P Ear ache/itch Y P Dizziness Y P NOSE & SINUSES Frequent colds Y P Nose bleeds Y P Stuffiness Y P Sinus problems Y P Post nasal drip Y P MOUTH & THROAT Frequent sore throat Y P Sore tongue Y P Sores in mouth /on lips Y P Gum problems Y P Hoarseness Y P Dental Problems Y P Fake teeth? How many? How many amalgam (mercury) fillings? Dental implants? If yes, what type? Dental bridges or partial bridges? If so, are they metallic? Any metal of any kind in your mouth? MENTAL / EMOTIONAL Depression Y P Mood Swings Y P Anxiety or nervousness Y P Tension Y P Suicide thoughts Y P Suicide attempts Y P ENDOCRINE Ever had any thyroid problem Y P Heat or cold intolerance Y P Hypoglycemia Y P Excessive thirst Y P Excessive hunger Y P Easy weight gain Y P CIRCULATION Deep leg pain Y P
5 Cold hands/ feet Y P Varicose veins Y P BLOOD Anemia Y P Easy bleeding or bruising Y P HEART Heart disease Y P High blood pressure Y P Rheumatic fever Y P Chest pain Y P Swelling in ankles Y P Palpitations, fluttering Y P 5
6 6 RESPIRATORY Cough Y P Spitting up blood Y P Wheezing Y P Difficulty breathing Y P Shortness of breath Y P Positive TB test ever? Y P DIGESTION Trouble swallowing Y P Heartburn Y P Take heartburn or acid reflux medicines? Bloating after eating Y P Change in appetite Y P Change in thirst Y P Loose stools Y P Blood in stools Y P Belching or gas Y P Liver/gall bladder disease Y P Hemorrhoids Y P Nausea Y P Vomiting Y P Bowels move: daily more less Use laxatives? What kind? Eat plenty of fiber? URINARY Pain on urination Y P Increased frequency Y P Frequency at night Y P Inability to hold urine Y P Bladder infections Y P Swellings anywhere in body Y P MUSCULOSKELETAL Joint pain or stiffness Y P Broken bones Y P Muscle spasms or cramps Y P Muscle spasms or cramps Y P Weakness Y P Date of last DEXA scan? NEUROLOGIC Fainting Y P Seizures Y P Paralysis Y P Muscle weakness Y P Numbness or tingling Y P Loss of memory Y P NECK Swollen glands Y P Pain or stiffness Y P MALE Hernias Y P Testicular masses Y P Testicular pain Y P Discharge or sores Y P Venereal disease Y P Difficulty stopping or starting urination Y P Prostate problems Y P Date of last prostate exam FEMALE Age menses began No. of days menstrual flow Length of complete cycle Are cycles regular Y P Bleeding between periods Y P Excessive flow Y P Cramps Y P PMS Y P Abnormal vaginal discharge Y P DATE of LAST PAP Smear Results were: normal abnormal don t know EVER had an abnormal PAP? Y P Date of last mammogram? Ever used birth control pills? Y P Ever used an IUD? Y P If so, how long? No. of pregnancies No. of live births No. of miscarriages No. of abortions Menopausal symptoms Y P Still have your own uterus? Yes or No? Still have your own ovaries? Yes or No? BREASTS Do you self exam regularly Y P Lumps Y P Pain or tenderness Y P Nipple Discharge Y P
7 7 Family History: Please check the boxes below for each condition that applies to one of your family members. Alcoholism Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Mental Illness Stroke Other significant disease(s) Mother Father Brother Sister Grandparent Circle all the diseases/disorders/conditions that apply, and then specify Now or Past. If both Now or Past apply, then check both columns. Conditions/diseases Acid reflux NOW PAST Allergies Anemia Arthritis, Rheumatoid Arthritis, Osteoarthritis Asthma Atherosclerosis ADD or ADHD Autoimmune diseases(s)? Which one(s)? (Lupus, MS, RA, myositis, sarcoidosis, etc.) Bladder infection BPH (Benign Prostatic Hyperplasia) Bronchitis Cancer, specify type(s)
8 8 Conditions/diseases Cholesterol, high or low? NOW PAST Constipation Crohn s disease Diabetes type 1 or 2 Diarrhea Diverticulitis/Diverticulosis Endometriosis Fibromyalgia Fibrocystic Breasts Heavy metal toxicity Hepatitis, specify type(s) Herpes High blood pressure (hypertension) Hyperthyroidism Hypoglycemia Hypothyroidism IBS IBD (Crohn s or Ulcerative colitis) Immune system malfunction (poor immune function, etc.) Insomnia Interstitial cystitis Libido (sex drive), low or high Kidney stones
9 9 Conditions/diseases Liver problems (fatty liver, enlarged liver, etc.) NOW PAST Memory loss or poor memory Menopausal symptoms (hot flashes, sweats, etc.) Menstrual problems (painful periods, bloating, etc.) Migraine headaches Obesity Osteopenia Osteoporosis Ovarian cysts PMS Prostatitis Psoriasis Restless legs syndrome Sciatica Shingles Sinusitis Tachycardia Triglycerides, high Tuberculosis Tumors, benign or malignant? Ulcerative colitis Uterine fibroids Ulcers Yeast infections, vaginal or gastrointestinal?
10 10
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