PATIENT INTAKE FORM Name: Date: Address: City: State: Zip: Telephone (home): ( ) (work): ( ) (cell): ( ) Email address: Age: Date of Birth: Gender: Female / Male Education: Occupation: Hours per week: Employer Name and Address: Status (circle): Married Separated Divorced Widowed Single Partnership Live with (circle): Spouse Partner Parents Children Friends Alone Race/Ethnic Origin (circle): African African American Asian Caucasian Native American Pacific Islander Hispanic Other: Name of spouse/partner: Name of parent(s) or guardian(s): Relationship to you: Emergency Contact: Relationship to you: Phone (home): ( ) (work): ( ) (cell): ( ) Address: How did you hear about this clinic? Has any other family member already been a patient at this clinic? Have you ever seen a Naturopathic Doctor (ND) before? Yes / No Would you like to receive health newsletters from the clinic as they become available? Yes / No
CONTEXT OF CARE REVIEW Successful health care and preventive medicine are only possible when the physician has a complete understanding of the patient physically, mentally and emotionally. The nature of your response to the following questions will go a long way in assisting my understanding of your truest desires. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to assist your health needs. Why did you choose to come to this clinic? What do you know about our approach? What three expectations do you have from this visit to our clinic? 1. 2. 3. What long term expectations do you have from working with our clinic? What expectations do you have of me personally as your health care provider? What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? Rate from 1 to 10, 10 being 100% committed. 0% 0 1 2 3 4 5 6 7 8 9 10 100% 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 are self destructive?
CONTEXT OF CARE REVIEW cont. What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and adhering to the therapeutic protocols which we will be sharing with you? Who do you know who 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 the first six levels of the career slice. Family & Friends Physical Environment Career Money Do the same for each area, starting from the center point radiating outward. CURRENT PROBLEM LIST What are your most important health problems? List them in order of importance and time of onset 1. 4. 2. 5. 3. 6. Do you have any known contagious diseases at this time? Yes / No If yes, what? Personal Growth Fun & Recreation Significant Other/ Romance Health
Please list any current diagnoses: 1. 3. 2. 4. Please mark your areas of pain Please indicate your CURRENT pain level on the chart below: I----------I----------I----------I----------I----------I----------I----------I----------I---------I----------I 0 1 2 3 4 5 6 7 8 9 10 (No pain) (Moderate pain) (Worst Pain) GENERAL Height: Weight: Weight one year ago: Maximum weight: When: Rate your energy during the day (time and level (1-10; 10=best) Best? Worst? Main interest and hobbies: Exercise: Y / N If so, what kind and how often: Watch TV: Y / N If so, how many hours? Read: Y / N If so, how many hours? Do you have a religious or spiritual practice? Y / N If so, what kind? Are you currently receiving health care? Yes / No If yes, where and from who? If no, are you planning to establish primary care with us? Y / N When and where did you last receive medical or health care? What was the reason? Do you currently have (circle): Advanced Directives Power of Attorney Will
FAMILY HISTORY Do you or anyone in your family have a history of any of the following? (Please circle and say who) Heart disease High cholesterol High Blood Pressure Diabetes Stroke Cancer Kidney disease Arthritis Anemia Asthma Glaucoma Mental illness Eczema Epilepsy Hay fever/hives Any other relevant family history? What is your family heritage? CHILDHOOD ILLNESSES Birth city and state: Birth time: Birth weight: Please circle whether you had any of the following as a child: Rheumatic fever Diptheria Scarlet fever Chicken pox German Measles Measles Mumps Ear infections VACCINE HISTORY (check all that apply) DPT (Diphtheria, Pertussis, Tetanus) Polio injection/polio oral HBV (Hepatitis B) Other (Flu shot, etc) What and When: Tetanus Booster (Usually DT) When? MMR (Measles, Mumps, Rubella) Hepatitis A vaccine HOSPITALIZATIONS/SURGERY/IMAGING What hospitalizations, surgeries, x-rays, CAT scans, EEG, EKGs have you had? ALLERGIES Are you hypersensitive or allergic to: Any drugs? Any foods? Any environmental or chemical?
ENVIRONMENTAL HISTORY Do you have amalgam fillings? Y / N If yes how many and for how long? Do you have past of current history of work related chemical exposure? Y / N If yes, what chemicals? Zip code of where you lived most of your life: MEDICATION Please list all medications (including over the counter) that you are currently taking and why. Please indicate dose and frequency. Have you taken Aspirin, Ibuprofen, Naproxen or any steroids for a long period of time (3 weeks or longer)? Y / N If yes for how long and for what? VITAMINS AND SUPPLEMENTS Please list all vitamins and supplements you are taking and why (Please indicate dose and frequency) TYPICAL FOOD INTAKE Breakfast: Lunch: Dinner: Snacks: Water: Coffee: Alcohol:
FOR THE FOLLOWING, PLEASE CIRCLE: Y=Yes, a condition you have now N=No, never had P=a significant problem in the past GENERAL ENDOCRINE CONT. Do you sleep well? Heat or cold intolerance? Average 6-8 hours? Hyperthyroid? Wake rested? Diabetes? Have a supportive relationship? Excessive hunger? Have a history of abuse? Seasonal depression? Experienced a major trauma? Difficulty exercising? Use recreational drugs? Treated for drug dependence? IMMUNE Use alcoholic beverages? Reactions to immunizations? Use tobacco? Chronically swollen glands? If in the past, how many years? Slow wound healing? How many packs per day? Chronic fatigue syndrome? Do you enjoy your work? Chronic infections? Take vacations? Night sweats? Spend time outside? Eat three meals a day? EARS Do you go on diets often? Impaired hearing? Do you eat out often? Ringing in ears? Do you drink coffee? Dizziness? Drink black/green tea? Ear infections? Drink soda? Do you eat refined sugar? EYES Do you add salt to your food? Impaired vision? Cataracts? NEUROLOGIC Glaucoma? Seizures? Spots in vision? Muscle weakness? Color blindness? Loss of memory? Tearing or dryness? Vertigo or dizziness? Eye pain or strain? Paralysis? Numbness or tingling? HEAD Easily stressed? Headaches? Loss of balance? Migraines? Head injury? ENDOCRINE Jaw or TMJ problems? Hypothyroid? Hypoglycemia? NOSE AND SINUS Excessive thirst? Frequent colds? Fatigue? Stuffiness?
NOSE AND SINUS CONT. Sinus problems? GASTROINTESTINAL Nose bleeds? Trouble swallowing? Hay fever? Change in thirst? Loss of smell? Change in appetite? Nausea/vomiting? NECK Ulcer? Lumps in neck? Jaundice? Goiter? Gall bladder disease? Difficulty swallowing? Liver disease? Pain or stiffness in neck? Hemorrhoids? Pancreatitis? MOUTH AND THROAT Heartburn? Frequent sore throat? Abdominal pain or cramps? Copious saliva? Belching or passing gas? Sore tongue or lips? Constipation? Hoarseness? Bowel movements: how often? Jaw clicks? Is this a change? Teeth grinding? Black stool? Gum problems? Blood in stools? Dental cavities? MENTAL/EMOTIONAL SKIN Treated for emotional problems? Rashes? Depression? Acne/boils? Anxiety or nervousness? Change in skin color? Poor concentrations? Lumps or bumps on skin? Do you have mood swings? Eczema or hives? Considered suicide? Itching? Attempted suicide? Perpetual hair loss? Tension? Memory problems? RESPIRATORY Cough? URINARY Sputum? Increased frequency of urination? Asthma? Inability to hold urine? Wheezing? Pain in urination? Bronchitis? Frequency at night? Coughing up blood? Frequent UTIs? Shortness of breath? Kidney stones? Shortness of breath when lying down? Pain in breathing? Emphysema? Tuberculosis?
MUSCULOSKELETAL FEMALE REPRODUCTIVE CONT. Joint pain or stiffness? Genital warts? Arthritis? Syphilis? Broken bones? Difficulty conceiving? Weakness? Are you pregnant? Muscle spasms or cramps? Number of pregnancies: Sciatica? Number of live births: Number of miscarriages: BLOOD Number of abortions: Anemia? Do you do self breast exams? Easy bleeding or bruising? Breast pain/tenderness? Cold hands/feet? Breast lumps? Deep leg pain? Nipple discharge? Thrombophlebitis? Menopausal symptoms? Varicose veins? MALE REPRODUCTIVE FEMALE REPRODUCTIVE Are you sexually active? Age of first menses: Sexual orientation: Age of last menses (if menopausal): Birth control? Type: Length of cycle: days Discharge or sores? Duration of menses: days Gonorrhea? Are your cycles regular? Herpes? Painful menses? Chlamydia? Heavy or excessive flow? Genital warts? PMS? Syphilis? Symptoms: Hernias? Testicular masses? Bleeding between cycles? Testicular pain? Clotting? Prostate disease? Endometriosis? Impotence? Ovarian cysts? Premature ejaculation? Vaginal odor? Date of last annual exam: Vaginal discharge? Date of last PAP smear: Abnormal PAP? Cervical dysplasia? Are you sexually active? Sexual orientation: Birth control? Type: Pain during intercourse? Gonorrhea? Herpes? Chlamydia?