Marlane Bassett, ND 3769 SE Milwaukie Ave. Portland OR Tel

Transcription

1 NEW PATIENT INTAKE Name Date: / / Address City State Zip Code: Telephone (circle best number to use): (h) (c) Is it ok to leave a message? Y N address (w) check to be included on mailing list Age Date of birth Gender Female Male Marital Status: Single Married Partnered Widowed Separated Divorced Living with: Spouse Partner Family Roommate(s) Alone Other How many people live in your household? Relationship: Do you have any pets?: Do you have a spouse, partner or significant other? (Circle one) Yes No Is this relationship supportive? (Circle one) Yes No What is your family heritage? Education Occupation: Hours worked per week: Will your insurance pay for your visit today? (Circle one) Yes No How did you hear about our clinic? Referral Google Other Has any other family member already been a patient at this clinic? Emergency contact Relationship Phone Address Why did you choose to come to this clinic? What do you know about Dr. Bassett s approach? What are your goals in working with Dr. Bassett? What 3 expectations do you have from your first visit? What do you expect from Dr. Bassett personally as your healthcare provider? 1

2 What is your level of commitment to making lifestyle changes in order to work toward your health care goals? Scale of 0-100% 0% % What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? What behaviors or lifestyle habits do you currently engage in regularly that you believe do not support your healthcare goals? What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and ability to adhere to the therapeutic protocols which we will be sharing with you? Who do you know that will sincerely and consistently support you with the beneficial lifestyle changes you will be making? What do you love to do? WHEEL OF BALANCE Wellness is a balance of many factors. Using the circle, shade your level of satisfaction in each area as it relates to you. For example, if you are 60% satisfied in your career, shade in 60 % of the career slice. Do the same for each area, starting from the center point radiating outward. What are your most important health problems?

3 How long have you had the PRIMARY problem? (Check only one) For less than one month For more than one month but less than two years For more than two years Which other health care providers have you seen previously for your PRIMARY problem? (Check all that apply) Medical doctor/specialist or Osteopathic doctor for medication or surgery Osteopathic doctor or chiropractor for manipulation Another naturopathic doctor Acupuncturist or Chinese medical doctor Homeopath Massage therapist or other physical therapist Nutritionist or herbalist Are you currently receiving healthcare? Yes / No If yes, where and from whom? If no, when and where did you last receive medical or health care? What was the reason? What self-prescribed treatments have you tried for your PRIMARY problem? CURRENT MEDICATIONS Do you take or use any of the following (Please circle and indicate how often you take): Laxatives Pain relievers Antacids Cortisone Antibiotics Tranquilizers Sleeping pills Thyroid medication Birth control pills Hormone replacement. Appetite suppressant Please list any prescription medication, over the counter medications, vitamins, or supplements you are taking: Do you have any known contagious diseases at this time? (Circle one) Yes No If yes, what? 3

4 GENERAL Height Weight Weight one year ago Maximum weight When HABITS When during the day is your energy the best? Exercise: Y / N If so, what kind and how often? Watch TV: Y / N If so, how many hours? Worst? Read: Y / N If so, how many hours? Tobacco Use: Cigarettes: Never Quit, date Current, packs/days for years Other: 2 nd hand smoke Pipe Cigar Snuff Chew Alcohol Use: Do you drink alcohol?: Never Past, # drinks/wk Current, # drinks per week Have you ever been treated for alcoholism? (Circle one) Yes No If yes, how often? Drug use: Have you ever used recreational drugs?: Never Past Current Have you ever been treated for drug dependence? (Circle one) Yes No If yes, how often? Caffeine Intake: Never Yes, I drink coffee/caffeinated tea/soda/cocoa (circle) cup/day Refined sugar intake: Never Yes, times per day Do you have any religious or spiritual practice? Y / N If so, what kind? What hospitalizations or surgeries have you had? Please include the year. Do you have any allergies to foods, drugs or environmental substances? A= Always, U = Usually, O=Often, S=Sometimes, N= Never Eat 3 meals a day Eat in restaurants Sleep well Diet to lose weight Awaken rested Add salt to your food Enjoy your work Spend time outside Take vacations 4

5 PREVANTIVE SCREENING TEST: please list the most recent date and the test s result. Routine Blood Tests: Date: Results: Normal Abnormal Sigmoidoscopy or Colonoscopy: Date: Results: Normal Abnormal Women: Pap Smear Date: Results: Normal Abnormal Mammogram: Date: Results: Normal Abnormal Ultrasound Date: Results: Normal Abnormal Other breast imaging: Date: Results: Normal Abnormal Dexascan (osteoporosis): Date: Results: Normal Abnormal Men: PSA (prostate) Date: Results: Normal Abnormal What diagnostic imaging studies have you had? (Please mark all that apply) X-rays CT scan MRI Electrocardiogram Electroencephalogram Other Underline which of the following conditions you have been immunized against. Circle if you actually had the condition. Polio Diphtheria/Pertussis/Tetanus Scarlet fever Chicken pox Measles/Mumps/Rubella Rheumatic fever Flu Small pox H. Influenza Frequency Y= Experience currently N=Never P=Past Severity: S=Severe, N= Not Severe HEAD EARS EYES S N Headache/migraine/tension (circle one) S N Head injury S N Jaw or TMJ problems S N Dandruff S N Itchy ears S N Earache/infections S N Dizziness S N Impaired hearing S N Ringing ears S N Watery/itchy eyes S N Dry eyes S N Impaired vision S N Glaucoma S N Cataracts S N Color blindness NOSE S N Frequent colds S N Sinus problems S N Stuffy nose S N Hay fever S N Nose bleeds S N Loss of smell MOUTH AND THROAT S N Frequent sore throat S N Copious saliva S N Sore tongue or lips S N Hoarseness S N Jaw clicks S N Teeth grinding S N Gum problems S N Dental cavities S N Canker sores S N Cold sores S N Bad breath 5

6 NECK S N Lumps S N Swollen glands S N Pain or stiffness S N Goiter S N Difficulty swallowing MENTAL EMOTIONAL S N Depression S N Anxiety or nervousness S N Poor concentration or comprehension S N Do you have mood swings? S N Considered suicide S N Attempted suicide S N Tension S N Memory problems S N Hallucinations ENERGY/ACTIVITY S N Fatigue/sluggishness S N Hyperactivity S N Restlessness HEART S N Irregular or skipped heartbeat S N Rapid or pounding heartbeat S N Chest pains S N Swelling in ankles S N History of heart attack S N High cholesterol LUNGS S N Cough S N Sputum S N Asthma S N Wheezing S N Bronchitis S N Coughing up blood S N Shortness of breath S N Shortness of breath lying down S N Pain in breathing S N Emphysema S N Tuberculosis BLOOD S N Anemia S N Easy bleeding or bruising S N Cold hands/feet S N Deep leg pain S N Thrombophlebitis S N Varicose veins DIGESTIVE S N Frequent nausea/vomiting S N Diarrhea S N Constipation S N Bloated feeling S N Belching or gas S N Heartburn S N Jaundice (yellow skin) S N Change in thirst S N Change in appetite S N Loss of taste S N Ulcer S N Gall bladder disease S N Liver disease S N Pancreatitis S N Blood in stool S N Mucus in stool S N Undigested food in stool S N Black stool S N Rectal itching S N Hemorrhoids WEIGHT S N Binge eating/drinking S N Craving certain foods S N Excessive weight S N Compulsive eating S N Water retention S N Underweight BOWEL MOVEMENTS: How often? Is this a change? Yes No 6

7 URINARY S N Increased frequency of urination S N Inability to hold urine S N Pain in urination S N Frequency at night S N Frequent UTI s S N Kidney stones MUSCULOSKELETAL S N Joint pain S N Arthritis S N Stiffness/limitation of movement S N Muscle pain S N Muscle weakness S N Numbness or tingling in arms or legs S N Muscle spasms or cramps S N Broken bones S N Sciatica SKIN S N Acne, boils S N Hives, rash S N Dry skin S N Itching S N Eczema S N Psoriasis S N Lumps S N Warts S N Excessive sweating NEUROLOGIC S N Seizures S N Muscle weakness S N Loss of memory S N Vertigo or dizziness S N Paralysis S N Numbness or tingling S N Easily stressed S N Loss of balance ENDOCRINE S N Hypothyroid S N Hypogylcemia S N Excessive thirst? S N Heat or cold intolerance S N Hyperthyroid S N Diabetes S N Excessive hunger S N Seasonal depression S N Difficulty exercising IMMUNE S N Reactions to immunizations S N Chronically swollen glands S N Slow wound healing S N Chronic fatigue syndrome S N Chronic infections S N Night sweats SLEEP S N Difficulty falling asleep S N Jerking on falling asleep S N Interrupted sleep S N Sleep walking S N Talking in sleep S N Grinding teeth in sleep Number of hours per night: Favorite sleep position: Stay covered during the night? Y N Stick feet out of covers? Y N Wear socks to bed? Y N Feeling on waking in morning Feeling on waking from nap 7

8 REPRODUCTIVE Are you sexually active? (Circle one) Yes No Sexual orientation: Do you use birth control? (Circle one) Yes No If yes, which form? Which method(s) have you used in the past: Pill Natural family planning IUD Diaphragm/cervical cap Condoms Have you had any sexually transmitted infections? If so, which ones? MALE REPRODUCTIVE Y= Experience currently N=Never P=Past Hernias Testicular masses Testicular Pain Prostate disease Discharge or sores Sexual difficulties FEMALE REPRODUCTIVE Y= Experience currently N=Never P=Past Bleeding between periods Pain during intercourse Painful menses Irregular cycles Excessive flow Menopausal symptoms Sexual difficulties Vaginal discharge or odor Ovarian cysts Endometriosis Nipple discharge PMS Age at which menses began: Age of last menses years Duration of bleeding days Average length of cycle days Number of pregnancies: Number of live births: Number of miscarriages: Number of abortions: Have you ever had trouble conceiving? (Circle one) Yes No Do you do self-exams? (Circle one) Yes Did you breast feed any of your children? (Circle one) Yes No If yes, how long? No Have you ever used any kind of hormone replacement therapy? (Circle one) Yes No If yes, what kind: 8

9 Self and Family History Please indicate the health status of you and your family Self Father Mother Brother 1 Brother 2 Brother 3 Sister 1 Sister 2 Sister 3 Mother s Father Mother s Mother Father s Father Father s Mother Age (at death) Cause of death Age (if living) Health (Good, Poor) List any significant health concerns of any of your family member: 9