NATUROPATHIC INTAKE FORM
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- Jeffery Fisher
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1 NATUROPATHIC INTAKE FORM Name: Today s Date: Address: City: Prov.: PC: Telephone: (Home) (Work) (Cellphone): Occupation: Date of Birth: Sex: M / F Where did you first hear about me? (please be specific: name of friend, website, farmer's market, name of doctor etc) Emergency Contact Name: Relation: Phone: Other phone: Other Health Care Providers: What are your health concerns? Please list in order of importance to you and how long you have been experiencing them: What, if any, measures have you previously taken to help with your health concerns? (circle all that apply) Diet changes Exercise Osteopathy Vitamins/minerals Prescription medication Massage Herbs Acupuncture Yoga/meditation Chiropractic Physiotherapy Surgery
2 Previous Medical History - please list any conditions, illness/injury or hospitalizations: Allergies (please list): Medications ( please list all current medications): Supplements ( please list current supplements): Past prescription medications (please list): Do you frequently take any of the following medications? Birth control pills Laxatives Cough medications Ibuprofen Cold/flu medications Allergy medications Tylenol Antacids Family Medical History - please indicate which relatives (parents, children, siblings, grandparents) suffer from the following conditions: Cancer (which type) High Blood Pressure Diabetes High Cholesterol Asthma Heart Disease (Heart Attack, Stroke etc) Thyroid Dysfunction Gastrointestinal Problems (celiac, Crohn's, etc) Allergies 2
3 Mental Illness Autoimmune How much tobacco do you consume per week? Did you previously consume tobacco? How much and for how long? How much alcohol do you consume per week? How much caffeine do you consume per week? Do you use recreational drugs? What type and how often? What were the most stressful events in your life? Do they still affect you now? What are the major causes of your current stress? (please circle) Financial Family Fertility Relationship Career Unfulfilled expectations Health Day-to-day life How does stress show up for you (get angry, eat more, sleep less, etc)? Diet - please describe a typical day's food intake: Breakfast Lunch 3
4 Dinner Snacks Do you have any foods that you do not eat? Are you a: Meat eater / Vegetarian / Vegan (please circle) What is your occupation? How many hours a week do you work? Do you work shift work? On a scale of 0 to 10 how happy are you with your job (10 = very happy) What are your main interests and hobbies? Do you have time to enjoy them? When do you feel happiest? _ Height: Weight: Max Weight: Weight 1 year ago: Review of Systems (please answer Y = yes, O = occasionally, P = past Skin: Eczema Rashes Hives Acne Boils Itching Lumps Night Sweats Dry skin (year round/winter only) Moist skin Nail changes Changes in mole 4
5 Skin cancer Head: Headaches Hair loss Head injury / concussion Eyes: Impaired vision Glasses / contacts / laser surgery Sensitivity to the sun Tearing Redness Itchy Floaters / blind spots Dry Double vision Glaucoma Cataracts Blurring Discharge Ears: Impaired hearing Ringing Earache Vertigo Excessive wax Infections 5
6 Nose: Frequent colds Nose bleeds Stuffiness Sinus problems Allergies Mouth/Throat: Frequent sore throat Ulcerations/ cankers Gum problems Hoarseness Cavities Bad breath Loss of taste Respiratory: Cough Cough up sputum Spit up blood Asthma Bronchitis Pneumonia Emphysema Difficulty breathing Tuberculosis Last chest ex-ray Cardiovascular: Heart attack Stroke 6
7 Angina High blood pressure Murmurs Chest pain Palpitations/flutter ing Swelling in ankles Increased cholesterol Breasts: Do you do monthly self-exams? Y / N Lumps Pain / tenderness Fibrocystic breasts Nipple discharge Breast cancer Abdominal/Gastrointestinal: Trouble swallowing Heartburn Change in appetite Nausea Vomiting Vomiting blood Do you strain to have a bowel movement? Y / N Is there undigested food in your bowel movement? Y / N Blood in stool Constipation Diarrhea Hemorrhoids Black, tarry stools Grey stools 7
8 Belching or passing gas Liver disease Gall bladder problems Ulcer Abdominal pain Hernia Rectal bleeding (blood on toilet paper) How often do you have a bowel movement? Is this a change? Y / N Urinary: Pain on urination Increased frequency Frequency at night Inability to hold urine Frequent infections Kidney stones Blood in urine Urgency Hesitancy Male Reproductive: Hernia Testicular mass Testicular pain Enlarged prostate Are you sexually active? Sexually Transmitted Infections Sexual difficulties Discharge Genital sores Genital rash Sexual preference: heterosexual / homosexual / bisexual Fungal infections (jock itch/athlete's foot) 8
9 Female Reproductive: Age menses began Length of cycle (day 1 to day 1): Are cycles regular Avg length of menses (including spotting) Last menstrual period Date: Bleeding between periods Painful menses Excessive flow PMS Pain during intercourse Vaginal discharge Vaginal itching Frequent yeast infections Fibroids Date of last PAP: Number of pregnancies: Number of live births: Number of miscarriages: Number of abortions: Difficulty conceiving Are you sexually active Sexual difficulties Sexually transmitted Sexual preference: infections heterosexual / homosexual / bisexual Genital rash Genital sores Neurological: Fainting Involuntary movement Paralysis Seizures/convulsion s Muscle weakness Numbness/tingling Loss of memory Loss of balance Speech Problems Brain Fog Endocrine: Heat intolerance Cold intolerance Problems with Excessive thirst thyroid Excessive hunger Excessive urination Excessive sweating Diabetes Hormone therapy Musculoskeletal: Joint pain Joint swelling Stiffness Arthritis 9
10 Muscle cramps/spasms Backache Weakness Peripheral Vasculature: Deep leg pain Cold hands/feet Varicose veins Thrombophlebitis Leg cramps Extremity ulcers Blood and Lymphatic: Anemia Past transfusions Easy bleeding/bruising Swollen lymph nodes Emotional: Depression Mood Swings Anxiety/Nervousnes Tension s Phobias Insomnia Patient information and Consent Form Naturopathic treatment is gentle and suitable for people of all ages from newborn to the elderly. At your first appointment, you can expect a thorough physical examination and history taking which may involve the ordering of bloodwork or requisition of labs/imaging ordered by your doctor. Some therapies must be used with caution when dealing with certain conditions (pregnancy/lactation, heart disease, kidney disease etc). It is very important that you inform your naturopathic doctor of any conditions you may be suffering from, as well as, update them if you begin to suffer from a new condition. You must notify your naturopathic doctor of any forms of medication, herbs, or supplements you are taking so that they can make sure there are no interactions. There exists a slight health risk when receiving treatment by naturopathic medicine. These risks include, but are not limited to, aggravation of pre - existing symptoms, allergic reaction to supplements or herbs, pain, bruising, fainting or injury from acupuncture and puncturing of an organ by acupuncture needles. The practitioner will answer any questions you may have to the best of their ability. While we use our professional skills to do our upmost to help you with your problems, we cannot guarantee the outcome because every patient is different. I give permission to contact my doctor(s) to report or gather information on my diagnosis, treatment plan and progress 10
11 Do you consent to treatment? Yes No Your consent may be revoked at any time if you choose. Signature: Date: Printed Name: 11
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Birch Wellness Center
Dr. Kelly Brown drkbrownnd@gmail.com Birch Wellness Center 34 Carlton Street, Winnipeg, Manitoba R3C 1N9 204 505 0325 (f) 204 505 0327 Full Legal Name: (Last, First) / Preferred Name: Date of Birth: Age:
Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
Name Date These questions that you are about to answer are very important for the Doctor. They will enable the doctor make a complete and diagnosis, and provide medical documentation (if needed)to your
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
New Adult Intake Form
New Adult Intake Form Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. Name: Today s Date: Age: Date of Birth
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): Email address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Ayurvedic Intake Form
Ayurvedic Intake Form Name: Today s Date Date of birth: Time of birth: Place of birth: Place of childhood: Other Places lived: Current address: Home phone: Work phone: Email address: Occupation: Age: Sex:
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Medical History Form
Medical History Form Full Name Title: Mr/Mrs/Ms/Miss Address Date of Birth Date Telephone: Mobile: Email: How did you hear about the Garden of health? G.P s Name and Address Are you currently seeing your
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician