Good News Naturopathic Clinic 83 East Ave STE 209, Norwalk CT (Tel) (Fax) New Patient Intake Form

Transcription

1 Date: New Patient Intake Form Last Name: First Name: DOB: Age: Sex: M F SSN: Street Address: City: State: Zip: Insured? Y N Insurance Provider: Occupation: Employer: Home Phone: Cell Phone: Work Phone: Preferred number to reach you: OK to leave voic ? Y N address: Relationship Status: Single Married Partnership Separated Divorced Widowed EMERGENCY CONTACT INFORMATION Name: Relationship: Phone: How did you hear about us? apple Referral from Health Care Provider Name: apple Patient Referral Name: apple Nutrition Workshop apple Internet Search apple Other (please specify): When did you last receive health care, and for what reason? 1

2 Reason for today s visit: Please list your primary health concerns/goals (in order of importance): Please list all MEDICATIONS you are currently taking, including over-the-counter medications. apple I currently do not take any medications. 1. Medication Reason Date/year started? Dose/Frequency Helpful? Y or N Please list all SUPPLEMENTS you are currently taking, including vitamins, minerals, herbal, and others. apple I do not currently take any supplements. Supplement Name (ex: Vitamin B12) 1. Supplement Brand (ex: Nature s Way) Date/year started? Dose/Frequency Helpful? Y or N

3 Please list any known drug, food or environmental allergies: PAST MEDICAL HISTORY Yes (Y), Past (P), No (N) Have you been immunized? Y N If yes, please specify: Immunization Y or N Date(s) Received Polio Y N Measles, Mumps, Rubella Y N Diptheria Y N Hepatitis B Y N Pertussis Y N Tetanus Y N Chickenpox Y N Influenza Y N Herpes Zoster (Shingles) Y N Tuberculosis Y N Pneumonia Y N Meningitis Y N Other (specify): Y N Have you had any adverse reactions to immunizations? Y N If yes, which one(s) and describe the adverse reaction: Have you served in the military? Y N Branch: Status: Active Veteran Have you recently traveled outside of the US? Y N If yes, where? Length of visit: Hospitalizations: Y N If yes, please list: Date Reason Length of Stay Surgeries: Y N If yes, please list: 3

4 Date Procedure Complications Family Member History of antibiotic use? If yes, what reason: FAMILY HISTORY Please indicate whether you or family member(s) has or had any of the following illnesses: Autoimmune Disease (specify) Cancer (specify) Cardiovascular Disease (specify) Diabetes Mood Disorders (specify) Neurological Disorders (specify) Thyroid Disease Self Mother Father Sibling(s) Child(ren) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather 4

5 If death directly resulted from any of the illnesses listed above, please note family member(s) and age of death: REVIEW OF SYSTEMS General: Weakness Chills Fatigue Night sweats Fever Have you had a weight gain or loss of 5 or more pounds within the past month? Y N If yes, how much many pounds gained or lost? Have you experienced any changes in appetite? Y N If yes, describe the changes: Have you noticed any changes in sleeping habits: Y N If yes, describe the changes: Head: Trauma Dizziness Headaches Lightheadedness Migraines Hair Loss Eyes: Double vision Glaucoma Blurriness Photophobia Cataracts Vision changes Dryness Eye pain Date of last eye exam: Ears: Earache Ringing ears Discharge Vertigo Hearing loss Trauma to ear 5

6 Nose: Sinusitis Congestion Loss of smell Nosebleeds Discharge Nasal fracture Polyps Mouth and Throat: Oral lesions Difficulty swallowing Bleeding/sore gums Sore throat Cavities Teeth grinding Hoarseness Impaired speech Date of last dental exam: Neck: Trauma Swollen glands Pain or stiffness Lumps Goiter Respiratory: Asthma Bronchitis Chronic cough Pneumonia Wheezing Sputum Emphysema Blood in sputum Tuberculosis Shortness of breath Difficulty breathing with lying down Rapid breathing with exertion Painful breathing at night Cardiovascular: High blood pressure Angina Murmur Chest pain Palpitations Dizziness Heart disease Swollen ankles/feet Leg pain (walking) Rheumatic fever Peripheral Vascular: Coldness of hands/feet Varicose veins Numbness of hands/feet Spider veins Deep leg pain Thrombophlebitis 6

7 Gastrointestinal: Heartburn Belching Bloody stool Gas/bloating Gallbladder disease Hemorrhoids Liver disease Jaunice/yellow skin Vomiting Nausea Vomiting of blood Ulcers Rectal pain/itching Loose stool How often are you having a bowel movement? Do you notice the following in your stool? Blood Mucous Undigested food Skin: Acne Boils Itching Rashes Lesions Hives Bruising/color changes Moles Eczema Dryness Genitourinary: Urge to urinate Frequent urination Blood in urine Painful urination Difficulty urinating Kidney stones Frequent infections Incontinence Urethral discharge Male Reproductive System: Hernia STDs Testicular Pain Testicular masses Sexual/penile dysfunction Prostate disease/pain Discharges/sores Genital warts Infertility Are you sexually active? If yes, please list safe sex practices: Have you had a prostate exam? If yes, please note date of last prostate exam: List abnormal findings, if any: 7

8 Female Reproductive System: Age of first menses: Normal puberty? Y N Length of cycle: Days of bleeding: Regular cycle? LMP: Birth control? What type? # of Pregnancies: Births: Miscarriages: Abortions: Pregnancy complications? Y N If yes, please explain: Do you have: Painful menses Painful intercourse PMS Heavy bleeding Missed periods Sexual dysfunction Menopause symptoms STDs Pelvic pain Vaginal itching/burning Spotting Vaginal discharge/sores Genital warts Are you sexually active? If yes, please list safe sex practices: Have you had a Pap smear? If yes, please note date of last Pap: List abnormal findings, if any: Please list menopausal or perimenopausal symptoms: Breast: Nipple discharge Enlargement Breast pain Tenderness Lumps/mass Skin discoloration Self-breast exams Have you had a mammogram? If yes, reason? Date of last mammogram? Abnormal findings? If yes, please explain: 8

9 Musculoskeletal: Joint pain/stiffness Broken bones Joint swelling Muscle cramps/spasms Arthritis Weakness Tenderness Muscle aches Neurological: Numbness/tingling Seizures Fainting Paralysis Tremors Memory loss Loss of sensation Loss of coordination Endocrine: Hot/cold intolerance Excessive thirst Excessive hunger Excessive urination Easy bleeding/bruising Anemia Low energy/fatigue Mental/Emotional: Anxiety/nervousness Excessive fears Depression Mood swings Easily angered Restlessness Suicidal thoughts Tension/Stress HEALTH HABITS: Drink alcohol? If yes, how many drinks a day or week? Smoke? If yes, how many cigarettes a day? Recreational drug use? If yes, please list: Have you ever been treated for alcohol or substance abuse? Y N If yes, please explain: Chemical or environmental exposures? Please list type of exposure and any symptoms you have experienced before, during or after exposure: 9

10 Do you currently exercise? Y N If so, how frequently and what activities? How many hours do you sleep? Insomnia? Y N Difficulty falling asleep or staying asleep? (circle one) Do you feel well-rested when you wake up? Y N Describe your energy on a scale of 1-10 (1=low; 10=high): Best time of day? Worst time of day? Please list any hobbies/interests: Please list any concerns that have not been addressed on this form. 10