Current History: What health concerns brought you in to the clinic today? (Order by importance)

Transcription

1 Adult Intake Form Personal Information Date: Name: Sex: M F Age: Address: Birth Date: City: Province: Telephone (Home): Postal code: (Work): Would you like to receive my newsletter (contains upcoming events, recipes, health tips)? Y/N Occupation: Employer: Marital status: Married Single Widowed Divorced Separated Common-Law Number of children: health care providers you are seeing: Name Occupation/Specialty Address Phone Fax In case of emergency, contact: Address: Relationship: Phone: How did you hear about Dr. Jennifer MacDonald, ND: Internet Search (what search term did you use?), Referral by someone (please specify who): (please specify): Have you seen a Naturopathic Doctor before: Yes No If yes, for what ailment(s)? Current History: What health concerns brought you in to the clinic today? (Order by importance)

2 Has anything changed recently or become worse? Medication and Supplement History Please list all supplements, herbs, and medications you are currently taking: Medication/Supplement Dosage Start Date Reason When was the last time you used antibiotics? Reason: How many times (approx) have you used antibiotics in your life? Do you frequently use any of the following? (check all that apply) Aspirin Laxatives Antacids Diet pills, Birth control: Pills Implants Injections Patch Alcohol. Which type(s): How many drinks per week (on average): Caffeine Form: Amount/day: Tobacco Form: Amount/day: Recreational drugs. What type? How often: Do you have a past history using any of the above? Do you have any allergies (medicines, environmental, etc.)? Please list any past medications/supplements: Medication/Supplement Start Date Reason 2

3 Please indicate what immunizations you have had: DPT (diphtheria, pertussis, tetanus) Haemophilus influenza B Hepatitis A Tetanus booster. When: Flu Hepatitis B MMR (measles, mumps, rubella) Polio Smallpox : Any adverse reactions? Gastrointestinal Health How often do you have a bowel movement? Do you tend towards: Constipation Diarrhea Both Neither Have you had blood in your stool? Yes No Mucus? Yes No Black, tarry stool? Yes No Do you have gas? Yes No Bloating? Yes No Reflux? Yes No Diet Do you have any food allergies or intolerances? Do you have dietary restrictions (religious), vegetarian/vegan, etc)? How much water do you drink per day? Please include a sample of a typical day s diet: Breakfast Lunch Dinner Beverages/Snacks Lifestyle/Environment Do you sleep well? Yes No On average, how many hours of sleep do you get a night? Do you exercise regularly? Yes No What do you do for exercise? How often? Are you exposed to significant tobacco smoke (work, home, etc)? Yes No Are you frequently exposed to animals (work, pets, etc)? Yes No Are you regularly exposed to toxins or other hazards? Yes No Which ones? Please rate your stress level: Low Average High Unbearable How would you describe the emotional climate of your home? 3

4 How do you deal with your stress? Women s Health Are you currently pregnant? Yes No Do you get Pap smears? Yes No Last Pap date: Have you had an abnormal Pap: Yes No Age of first period: Is your period regular? Yes No Length of cycle (Days): Flow (Days) Are you menopausal? Yes No If yes, age of last period: Are you currently sexually active? Yes No Have you been sexually active in the past? Yes No Current form of contraception: Have you ever had a sexually transmitted infection? Yes No Number of pregnancies? Live births? Miscarriages? Abortions? Do you have any sexual of concern? Yes no. If yes, please explain: Men s Health Do you get regular screening tests done (blood work, prostate examinations)? Yes No Date of last prostate exam? Are you currently sexually active? Yes No Have you been sexually active in the past? Yes No Current form of contraception: Have you had any of the following: Testicular pain Hernia STI s Discharge Sores Do you have any sexual of concern? Yes No. If yes, please explain: _ Chronological Health History How would you describe you current general state of health: Excellent Good Fair Poor This sort of history helps to establish trends in a person s health that may be relevant to present conditions. Indicate below any health conditions, accidents, broken bones, falls, illnesses, hospitalizations, surgeries and any emotional traumas such as deaths, loss of jobs, divorces, etc. Age 1-5 Age 6-10 Age Age Age Age Age

5 Age Age Age Age Age Age Age Age Age Age Age Family History Please indicate whether you or any of your family members have, or have had the following. Do you or anyone in your family have a history of any of the following? Please check and indicate who. M=mother, F=father, GM=grandmother, GF = grandfather, S=sister, B=brother, C=child Illness Relative Illness Relative Alcoholism Diabetes Allergies Drug Abuse Alzheimer s Disease Heart Disease Arthritis High Blood Pressure Asthma Kidney Disease Autoimmune disease Osteoporosis Cancer (Indicate type) Stroke Mental Illness Suicide Liver Disease Medical History Alcohol abuse Allergies Anemia Anxiety Asthma Arthritis Back, muscle, joint pain Bladder/urinary Cancer Candida Chicken pox Depression Diabetes Eczema Epilepsy Female reproductive Gallstones Gout Gum/teeth 5

6 Hay fever Heart attack Heart High blood pressure High cholesterol Hives Kidney Liver Malaria Measles Mononucleosis Mumps Overweight Pleurisy Pneumonia Psychological Rubella Sinusitis Skin Stroke Suicidality Thyroid Tuberculosis Ulcers Venereal disease Do you get regular SCREENING tests done by another doctor? (Pap, Blood Tests, Colonoscopy, etc) Yes No Is there anything that you feel is important that has not been covered? We would respectfully request 48 hours notice of any change in appointments. wise, you will be charged for a missed appointment. Full payment is to be made at the time of your visit. Cash, Cheque, Debit, Visa or Mastercard are accepted. Thank you for taking the time to fill out this form. The information collected will help you on your journey to achieving better health! 6

7 Review of Symptoms Please check Y if you currently have the symptom, and check P if you have had the symptom in the past. Skin Y P Rashes Hives Acne Boils Eczema Psoriasis Dry skin Itching Lumps Night Sweats Noses and Sinuses Y P Frequent colds Nosebleeds Stuffiness Hay fever Infections Excessive wax Head Y P Tension headaches Migraine headaches Head injury Dizziness Mouth and Throat Y P Hoarseness Gum Difficulty swallowing Dental Sores Dryness Sore throat Loss of taste Eye Y P Impaired vision Use of contact lenses Eye pain Tearing Dryness Double vision Glaucoma Cataracts Blurring Light sensitive Itching Redness Discharge Blind spot Ears Y P Impaired hearing Earache Dizziness Discharge Infections Neck Y P Lumps Swollen glands Goiter Pain or stiffness Respiratory Y P Cough Sputum Spitting up blood Wheezing Asthma Bronchitis Pneumonia Pleurisy Emphysema Difficulty breathing Difficulty breathing at night Pain on breathing Positive tuberculin test 7

8 Cardiovascular Y P Angina Murmurs Chest pain Swelling in ankles Palpitations, fluttering Last ECG Gastrointestinal Y P Trouble swallowing Heartburn Change in appetite Nausea Vomiting Vomiting blood Belching Passing gas Abdominal pain Indigestion Diarrhea Constipation Blood in stool Hemorrhoids Black, tarry stool Jaundice Liver disease Gallbladder disease Food allergy Hiatus hernia Last colonoscopy Blood/Lymphatic Y P Anemia Easy bruising/bleeding Past transfusions Lymph node swelling Urinary Y P Pain on urinary Increased frequency Frequency at night Inability to hold urine Frequent infections Kidney stones Blood in urine Reduced urine flow Musculoskeletal Y P Broken bones Muscle spasms/cramps Weakness Joint swelling Backache Peripheral Vascular Y P Deep leg pain Cold hands and feet Varicose veins Thrombophlebitis Leg cramps Extremity numbness Extremity coldness Extremity swelling Extremity ulcers Neurologic Y P Fainting Seizures/convulsions Paralysis Muscle weakness Numbness or tingling Loss of memory Involuntary movements Loss of balance Speech Endocrine Y P Heat or cold intolerance Thyroid trouble Excessive thirst Excessive hunger Excessive urination Excessive sweating Diabetes Hypoglycemia Hormone therapy Female Reproductive Y P 8

9 Check sexual preference: Heterosexual Homosexual Bisexual Age of first menses Last menstrual period Number of days of menses Length of cycle Bleeding between periods Irregular cycles Pain during intercourse Painful menses Excess flow PMS Sexual difficulties Vaginal discharge Vaginal itching Sexually active Sexually transmitted infections Number of pregnancies Number of live births Number of miscarriages Number of abortions Difficulty conceiving Menopause Age of onset Hormone therapy Last gynaecological exam Last pap smear Breasts Y P Lumps Pain or tenderness Nipple discharge Last mammogram Male Reproductive Y P Check sexual preference: Heterosexual Homosexual Bisexual Hernia Testicular masses Testicular pain Impotence Premature ejaculation Sexually transmitted infections Sexually active Last prostate exam Last PSA level Emotional Y P Depression Anxiety Anger Mood swings Nervousness Tension Phobias Insomnia Sexual difficulties Drug abuse Psychiatric care Psychological counselling 9