ADULT INTAKE FORM - NATUROPATH Date:

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Transcription:

ADULT INTAKE FORM - NATUROPATH Date: Name Date of Birth Gender (please circle) F M Weight (current) lbs Marital Status Single Married Divorced Partnership Height (inches or cm) Widowed Other Do you have children? Y N If so, list their ages Occupation Gender (s)? Contact Information Address Phone Number (Day) E-mail address City, Province Phone Number (Evening) Postal Code Phone Number (Cell) Emergency Contact Name Phone number Relationship Health Care Provider Information: Family doctor: Other health care provider: Phone number: Phone number: Health Card Number May we contact your health care providers to update them on your progress? Y N Where did you hear about us? Internet Yellow Pages Friend Physician Other List your primary health concerns, in order of importance: 1. 2. 3. List ALL prescription and over-the-counter medications you are currently taking Medication, daily dose Date started Medication, daily dose Date started Medication, daily dose Date started Supplements List all vitamins, minerals, herbs or other supplements that you take. Name of supplement Daily dose Name of supplement Daily dose Have you received naturopathic treatment in the past? Please circle Yes No What expectations do you have of me as your Naturopathic Doctor? 1

Reversing illness by treating the underlying cause and effectively managing health does not happen overnight. It often requires a commitment to lifestyle change. How would you describe your present level of commitment to making changes in your health on a scale from 1 to 10? (0%) 0 1 2 3 4 5 6 7 8 9 10 (100%) Medical History How would you describe your current state of health? Excellent Good Fair Poor Please indicate any serious conditions, illnesses, injuries, surgeries, and/or hospitalizations that you have had in the past Have you had one or more of the following illnesses? Please check all applicable boxes. Scarlet fever Diphtheria Rheumatic fever Mumps Measles Mononucleosis Chicken pox Shingles Tuberculosis Vaccinations Vaccinations administered Date Received Adverse reactions MMR (Measles, Mumps, Rubella) DTPP (Diphtheria, Tetanus, Pertussis, Polio) Haemophilus influenza type B Pneumococcal Meningitis Chicken pox Influenza Hepatitis A Hepatitis B Small Pox Gardacil Other Allergies Do you have any allergies (environmental, foods, drugs, supplements)? Y N Please list _ Have you ever had an anaphylactic reaction (hives, trouble breathing, etc.)? Y N Please explain to what (if known) and what occurs: _ Family History Mother/Father Mother/Father Sibling 1 Sibling 2 Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother Age/Age at death General health (ie. excellent, poor) Health conditions 2

Lifestyle How often do you eat in a day? What foods do you crave and how often do you eat those foods? Do you have any food sensitivities? Do you drink alcohol? Y N How often? (times/day/wk) other Do you (or have you) smoked cigarettes/cigars/used tobacco? Please circle Y N If so, please list the quantity per day/wk/month Do you use recreational drugs? Y N What types and how often? Work & Play How did you get into your line of work, and do you enjoy it? When was your last vacation? What do you do for fun? Do you exercise? How often? Mental/Emotional How would you describe the emotional climate of your home? _ How stressful is your life and how do you feel you cope with these stressors? _ Sleep & Energy How many hours do you sleep per night? Bed time? Wake time? Do you fall asleep easily? Y N Do you wake refreshed? Y N If not, how long might it take? (mins, hr) Do you experience sweating at night? Y N Do you wake during the night? Y N What time and how often? Can you fall back to sleep easily? Y N What time of day is your energy best? Worst? Any unexplained weight loss or weight gain? Y N If so, please explain. Review of Systems Please circle C if you are currently experiencing the symptom, N if you have never experienced this issue, or P if you have experienced any of the following in the past that was a significant health concern (you may circle both current and past if both are applicable) SKIN Eczema C N P Psoriasis C N P Acne C N P Hair loss C N P Itching C N P Dryness C N P Skin colour changes C N P Lumps and/or bumps C N P Hives C N P Change in a mole C N P HEAD & NECK Headaches C N P Head Injury C N P Migraines C N P Swollen glands C N P Goiter C N P Dizziness (Vertigo) C N P 3

EYES Glasses and/or contacts (please circle) C N P Double vision C N P Eye pain C N P Spots in vision C N P Tearing or dryness C N P Blurred vision C N P Glaucoma C N P Colour blindness C N P Itching C N P Cataracts C N P Significant discharge C N P Blind spot C N P Redness C N P EAR, NOSE & THROAT Impaired hearing C N P Ringing C N P Earaches C N P Meniere s disease C N P Discharge C N P Ear infections C N P Sinusitis C N P Nose bleeds C N P Stuffed-up nose C N P Snoring C N P Frequent sore throat C N P Hay fever C N P Teeth grinding C N P Loss of smell C N P Gum problems C N P Loss of taste C N P Amalgam (mercury) fillings C N P Sore tongue/mouth C N P Clicking of the jaw C N P Hoarseness C N P LUNGS Cough C N P Pain when breathing C N P Spitting up blood C N P Spitting up mucous C N P Asthma C N P Wheezing C N P Pneumonia C N P Bronchitis C N P Emphysema C N P Shortness of breath C N P Tuberculosis C N P Shortness of breath lying down C N P CARDIOVASCULAR High blood pressure C N P Angina C N P Low blood pressure C N P Murmurs C N P Blood clots C N P Fainting C N P Phlebitis C N P Palpitations/fluttering C N P Rheumatic fever C N P Chest pain C N P Swelling in ankles C N P Past ECG (Echocardiogram) GASTROINTESTINAL Trouble swallowing C N P Change in thirst C N P Nausea C N P Change in appetite C N P Vomiting C N P Heartburn/Indigestion C N P Vomiting blood C N P Constipation C N P Blood in stool C N P Diarrhea C N P Abdominal pain or cramps C N P Worms/Parasites C N P Belching or passing gas C N P Gall Bladder stones C N P Black, tarry stools C N P Ulcer C N P Jaundice (i.e., yellow skin) C N P Hemorrhoids/fissures C N P Liver disease C N P Hernia C N P Bowel movements how often? Change in bowel movements C N P 4

URINARY Pain on urination C N P Frequent infections C N P Increased frequency of urination C N P Inability to hold urine C N P Urination at night C N P Kidney stones C N P Urgency or hesitancy C N P Blood in urine C N P MALE REPRODUCTIVE SYSTEM Prostatitis C N P Syphilis C N P Testicular pain or masses C N P Discharge or sores C N P Impotence? C N P Chlamydia C N P Premature ejaculation? C N P Gonorrhea C N P Are you sexually active? C N P Genital warts C N P Do you use contraceptives? What type? C N P Herpes C N P FEMALE REPRODUCTIVE SYSTEM Age at first menses (period) Do you use birth control? C N P What methods? Age at last menses (i.e. Menopause) Pain during intercourse C N P Typical duration of bleed (ie. 5 d) Number of pregnancies Typical length of cycle (ie. 28 d) Number of live births Are cycles regular? C N P Number of miscarriages PMS C N P Number of abortions Painful menses C N P Menopausal symptoms? C N P Heavy or excessive flow C N P Hot flashes? C N P Bleeding between periods C N P Gonorrhea C N P Clotting during menses C N P Herpes C N P Unusual vaginal discharge C N P Chlamydia C N P Vaginal itching C N P Genital warts C N P Date of last PAP Syphilis C N P Abnormal PAP C N P Do you do breast self-exams? C N P Endometriosis C N P Have you had a mammogram? C N P Ovarian cysts C N P Breast pain or tenderness C N P Cervical dysplasia C N P Breast lumps C N P Are you sexually active? C N P Nipple discharge? Colour (clear, bloody, other)? C N P MUSCULOSKELETAL Joint pain or stiffness C N P Weakness in limbs C N P Broken bones C N P Sciatica C N P Muscle spasms or cramps in legs C N P Backache C N P Joint swelling C N P Neck pain/stiffness C N P BLOOD & PERIPHERAL VASCULAR SYSTEMS Easy bleeding/bruising C N P Low iron C N P Deep leg pains C N P Cold hands/feet/other C N P Varicose veins C N P Swelling in hands/feet C N P Numbness of hands/feet C N P Ulcers on hands/feet C N P 5

NEUROLOGICAL Seizures C N P Numbness or tingling C N P Muscle weakness C N P Speech difficulties C N P Involuntary body movements C N P Loss of balance C N P Paralysis C N P Nerve damage or irritation C N P ENDOCRINE Fatigue C N P Heat or cold intolerance C N P Excessive thirst C N P Low blood sugar C N P Excessive hunger C N P Excessive sweating C N P Excessive urination C N P Taking hormone therapy? C N P Night sweats C N P Temperature changes C N P MENTAL & EMOTIONAL Treated for emotional issues C N P Memory problems C N P Mood swings C N P Anxiety or nervousness C N P Poor concentration C N P Depression C N P Tension and/or stress C N P Considered/attempted suicide C N P Phobias C N P Seasonal depression C N P Commitment to Self What behaviours or lifestyle habits do you currently engage in regularly that you believe support your health? What are self-destructive to your health? Please list. What potential obstacles do you foresee in adhering to therapeutic protocols? Do you have people who will sincerely and consistently support you with the beneficial lifestyle changes you will be making? _ 6

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