New Patient Intake Form

Transcription

1 501 Islington Street, Suite 2B Portsmouth, NH P: F: New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work Mobile Is it OK to leave messages? yes no Address: City, State, Zip: Address: How did you hear about our office? If you were referred to us, who may we thank? Are you interested in receiving notifications of classes and lectures? yes no Emergency Contact Name: Relationship: Phone # H ( ) W ( ) Cell ( ) Address: City, State, Zip: Have you been to a Doctor of Naturopathic Medicine before? If yes, when? What were you being treated for? Were you satisfied with your care? If not, please explain: When was the last time you had medical care and for what reason? Name & Phone # of PCP: What are your primary health concerns? List them in order of importance to you: What is the primary expectation you have for your visit at our clinic today?

2 Health History Please list any known allergies (environmental, drug, food, animals, chemicals/perfumes): Do you take any of the following over-the-counter medications? Please check any that apply: Aspirin Ibuprofen or acetaminophen Antihistamine Sleeping pills Laxatives Appetite Depressants Antacid Medicine to stay awake Please list any pharmaceutical and/or natural medications (including vitamins) that you are taking or have taken in the last year. Medication Dosage Dates Reason for taking Which diagnostic studies have you had? Please indicate dates: Hospitalization Surgery X-ray MRI Rectal Exam Electrocardiogram Endoscopy Colonoscopy Mammogram CT Scan Bone Scan Other For the following conditions and symptoms, please indicate any that apply to you by marking a C for current or P for past: Skin rash Chronic pain Difficulty breathing Anemia Fatigue Chest pain Easy bleeding or bruising Weakness Heart palpitations Varicose veins or hemorrhoids Dizziness or fainting Atherosclerosis Bone or joint disease Numbness/tingling/paralysis Gastrointestinal paralysis Mood swings Neurological disease Heartburn Anxiety or nervousness Seizures Gastritis or ulcers Difficulty sleeping Memory loss Excessive thirst/hunger Feel unsafe at home Headaches Hypoglycemia Physical abuse Head injury Eating disorder Frequent antibiotic use Dental problems Parasites Frequent colds or flu Cold sores Liver disease HIV or AIDS Ear infections Gallbladder disease Lyme disease Impaired hearing/vision Kidney disease Rheumatic Fever Sinus problems Problems with urination Vaccinations Thyroid problems Sexual difficulties When are your symptoms worse?

3 Morning Afternoon At home At work Upon waking Evening Overnight No pattern Other: Family History If you or anyone in your immediate family has had any of the following conditions, please indicate who was affected (self, mother, father, sister, brother, child): Cancer Diabetes Heart Disease Asthma, hay fever, rashes Stroke Osteoporosis High blood pressure Depression Alcoholism or substance abuse Autoimmune disease Attempted suicide Other For Men Only Please check all that apply to you: Prostate exam / / Abnormal discharge from penis Regular self-testicular exam Pain or lump in scrotum Impaired fertility Prostate problem Sexual abuse Sexually transmitted infection For Women Only Last menses / / Please check all that apply to you: Last pap smear / / Hysterectomy / / Age menses began Abnormal pap smear Number of pregnancies Breast pain/lump/nipple discharge Number of live births Sexual difficulties Frequent vaginitis/chronic yeast infections If you are still having periods: Abnormal vaginal discharge Average number of days of bleeding Endometriosis Average number of days in cycle Polycystic ovary syndrome Bleeding is: Regular Irregular Sexually transmitted infection Light Medium Heavy Pelvic inflammatory disease Symptoms: Bleeding between periods Uterine fibroids Mood swings PMS Impaired fertility Painful menses Breast tenderness Sexual abuse Regular self-breast exam If you are no longer having periods: Sexually active Hot flashes Vaginal dryness Use methods to prevent pregnancy and/or sexually Dry skin Changes in memory transmitted infections: Spotting Changes in libido Current: Facial hair Changes in mood Past: Hair loss Hormone replacement therapy Incontinence Urinary tract infections

4 Lifestyle History Please check any that apply to you and fill in corresponding details: Exercise hours per week Height Activities Weight Watch TV hours per week Weight one year ago Tobacco use packs per day Maximum weight Alcohol drinks per day per week When? Recreational drug use Sleep hours per night Mercury amalgam fillings Is this enough? yes no Employed outside the home # of Meals per day Occupation Bowel movements per day Hours per week Dietary restrictions Employer Do you enjoy your work? yes no Level of stress Low Average High Toxic exposure Major life change in last year

5 Nicole Schertell ND, CCT Johanna Mauss, ND HIPAA CONSENT FORM I give this practice/clinic my consent to use or disclose my protected health information to carry out my treatment or to obtain payment from insurance companies. I have been informed that I may review the practice/clinic s Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice/clinic agrees to my requested restriction, they must follow the restriction(s). I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed. Signature: Date: Patient, parent or legal guardian If signed by patient representative, state relationship to patient: