Intake Forms Naturopathic healthcare is possible only when the physician completely understands the patient s physical, mental and emotional condition. The information you provide helps the doctor understand your needs and how to help you reach your health goals. Please answer all questions as completely as possible, and mark anything that you have a question about. And, welcome! (This form is in word and can be filled in on your computer. It is in a table format, please only mark in the lined or boxed spaces) Date Name Mailing Address City/State/Zip Shipping Address City/State/Zip Phone (home) Work Phone E-mail Emergency Contact City/State/Zip Phone (home/cell) Cell Phone Fax Address Work Phone Age Date of Birth Gender Female Male Genetic Background African European Native American Mediterranean Asian Middle Eastern Higher Education Level High School Under-Graduate Post-Graduate Occupation Employer by Referred by: Media (Please indicate source) Online (Google\Please list search words you used) Health Care Organization Friend or Family Name Current/Recent healthcare providers Name Dates Care Provided Naturopathic Medical Consent: I consent to services rendered and provided to me under the instructions of the staff physicians for Naturopathic Medicine. Financial Agreement: The undersigned, in consideration of services to be rendered to the patient, agrees to pay the provider of service, in accordance with their regular rates and terms, for the services rendered. All payment is due at time of service. The undersigned further agrees to pay reasonable attorney fees and expenses incurred in collecting all sums not paid when due, whether or not litigation is actually commenced, as well as all attorney fees and costs on appeal. I certify that the information that I have supplied is correct and accurate to the best of my knowledge. Signature: Date: Print Name: _ pg. 1
We understand that this is an extensive form. Get yourself a glass of water or tea, take your time. This form provides a big picture to your health. Please list current and ongoing problems in order of priority or concern Describe Problem Mild Mod. Severe Example: Post Nasal drip x MEDICAL HISTORY DIAGNOSIS/CONDITIONS/DISEASES This is a list of any diagnosis or problems you might have had or have. Check appropriate box and provide date of onset. Gastrointestinal Irritable Bowel Syndrome Inflammatory Bowel Disease Crohn s Ulcerative Colitis Peptic Ulcer Disease Cardiovascular Heart Attack Hearth Disease Stoke Elevated Cholesterol Arrhythmia (irregular heart rate) Metabolic/Endocrine Type 1 Diabetes Type 2 Diabetes Hypoglycemia Metabolic Syndrome Pre-Diabetes Hypothyroidism (low thyroid) Hyperthyroidism (overactive) Endocrine Problems Polycystic Ovarian Syndrome Infertility Genital and Urinary System Kidney Stones Gout Interstitial Cystitis Urinary Tract Infections Musculoskeletal/Pain Osteoarthritis Osteoporosis Osteropenia GERD (Reflux) Celiac Disease Gall Bladder Hypertension (high blood pressure) Rheumatic Fever Mitral Valve Prolapse Weight Gain Weight Loss Weight Fluctuations Bulimia Anorexia Binge Eating Disorder Night Eating Syndrome Eating Disorder (non-specific) Yeast Infections Erectile/Sexual Dysfunction Fibromyalgia Chronic Pain Inflammatory/Autoimmune Chronic Fatigue Syndrome Autoimmune Disease Rheumatoid Arthritis Lupus SLE Immune Deficiency Disease Herpes-Genital Severe Infectious Disease Respiratory Disease Asthma Chronic Sinusitis Bronchitis Emphysema Poor Immune Function Frequent Infections Food Allergies Environmental Allergies Chemical Sensitivities Pneumonia Tuberculosis Sleep Apnea pg. 2
Skin Diseases Eczema Psoriasis Acne Neurologic/Mood Depression Anxiety Bipolar Disorder Schizophrenia Headaches Migraines Autism Injuries Back Pain or Injury Head Pain or Injury Neck Pain or Injury Cancer Lung Cancer Breast Cancer Colon Cancer Ovarian Cancer Melanoma Skin Cancer Mild Cognitive Impairment Memory Problems Parkinson s Disease Multiple Sclerosis ALS Seizures Ankle Pain or Injury Broken Bones Prostate Cancer Skin Cancer Surgeries None Joint replacement Appendectomy Knee Hip Hysterectomy Heart Surgery Gall Bladder Angioplasty or Stent Hernia Pacemaker Tonsillectomy CURRENT MEDICAL HISTORY Blood Type A B AB Rh Rh+ Unknown Nutrition History (Continued) Height (feet/inches) Current weight Desired weight range +/- 5lbs MEDICATIONS Current Medications Medication Dose Frequency Start date (m0/yr) Reason for Use Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathic) Supplement Dose Frequency Start date (m0/yr) Reason for Use pg. 3
Current Medication Continue Have your medications or supplements ever caused you unusual side effects or problems? Yes No Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin? Yes No Have you had prolonged or regular use of Tylenol? Yes No Have you had prolonged or regular use of Acid Blocking Drugs (Zantac, Prilosec) Yes No Frequent Antibiotic >2 times a year Yes No Long term antibiotic use Yes No Use of steroids (prednisone, nasal allergy inhalers) in the past Yes No If yes, describe symptoms Do you have any known chemical sensitivity Yes No Do any of these significantly affect you Cigarette Smoke Perfumed/Colognes Auto Exhaust Fumes Do you have a known history of significant exposure to any harmful chemicals such as the following? Herbicides Pesticides Organic Solvents Heavy Metals Explain Sleep Average number of hours you sleep per night Yes No Do you sleep well? Yes No Do you wake up at night? Yes No If so, do you go back to sleep Yes No Do you have problems with insomnia Yes No Do you awake rested Yes No Do you use sleeping aids Yes No Explain Exercise Current Exercise Program (List the type of actively, number of sessions/week and duration) Activity Type Frequency per week Duration of minuets Nutrition History Have you made any changes to your diet because of your health If yes, please describe: What foods do you crave? Sweets Chocolate Salty Sour Breads Fatty Spicy How often do you eat How many times a day Do you have any immediate symptoms in associations with eating? Yes No Belching Bloating Abdominal pain Diarrhea Hives Post Nasal Drip Do fatty foods cause indigestion Yes No Does skipping a meal greatly affect you Yes Yes No No How often do you eat How many times a day Stress/Coping Do you have an excessive amount of stress in your life Yes No Do you feel you can easily handle the stress in your life Yes No Do you practice relaxation techniques or meditation Yes No If yes, what and how often Roles/Relationship Material status Single Married Divorced Widow Gay/Lesbian Long Term Partnership Family History Please check any disorder (d/o) if any family member has had and/or died from any of the following: Alcoholism Drug Addiction Allergies Asthma Anemia/Bleeding Arthritis Eczema / Psoriasis Genetic Disease Glaucoma Heart Disease High Cholesterol Immune Disorder High Blood Psi Kidney Disease Mental d/o Obesity Osteoporosis Parkinson s Psychiatric d/o Depression Mental d/o Ulcers Stroke Thyroid Disorders pg. 4
SYMPTOM SURVEY FORM Name Birth Date Date INSTRUCTIONS: Check in only the boxes which apply to you. 1 2 3 x MILD symptoms (occurred once or twice in last 6 months) x MODERATE symptoms (occurred once or twice last month) x SEVERE symptoms (chronic, occurred once or twice last week) 1 2 3 GROUP 1 Acid foods upset Get chilled often Lump in throat Dry mouth-eyes-nose Pulse speeds after meals Keyed up fail to calm Cut heals slowly Gag easily Unable to relax, startles easily Extremities cold, clammy Strong light irritates Urine amount reduced Heart pounds after retiring Nervous stomach Appetite reduced Cold sweats often Fever easily raised Neuralgia-like pains Staring, blinks little Sour stomach often GROUP 2 Joint stiffness on arising Muscle-leg-toe cramps at night Butterfly stomach, cramps Eyes or nose watery Eyes blink often Eyelids swollen, puffy Indigestion soon after eating Always seems hungry; lightheaded often Digestion rapid Vomiting frequent Hoarseness frequent Breathing irregular Pulse slow; feels irregular Gagging reflex slow Difficulty swallowing Constipation, diarrhea alternation Slow starter Gets chilled infrequently Perspire easily Circulation poor, sensitive to cold Subject to colds, asthma, bronchitis GROUP 3 Eat when nervous Excessive appetite Hungry between meals Irritable before meals Get shaky if hungry Fatigue, eating relieves Lightheaded if meals delayed Heart palpated if meals missed or delayed Afternoon headaches Overeating sweets upsets Awaken safer few hours sleep hard to get back to sleep Craves candy or coffee in afternoon Moods of depression blues Abnormal craving for sweets or snacks GROUP 4 Hands and feet go to sleep easily Sigh frequently, air under High altitude discomfort Opens windows in closed rooms Susceptible to colds and fevers Afternoon yawner Swollen ankles, worse at night Muscle cramps, worse during exercise; gets charley horses Shortness of breath on exertion Dull pain in chest or radiation into left arm, worse on exertion Bruise easily, black and blue spots Tendency to anemia Nose bleeds frequently Noises in head, or ringing in ears Tension under the breastbone, or feeling or tightness worse on exertion GROUP 5 Dizziness Dry skin Burning feet Blurred vision Itching skin an feet Frequent skin rashes Bitter, metallic taste in mouth in morning Bowel movement painful or difficult Worrier, feels insecure Feels queasy; headache over eyes Greasy food upset Stools light colored Skin peels on foot soles Pain between shoulder blades Use laxatives Stools alternating from soft to watery History of gallbladder attach sot gallstones Sneezing attacks Dreaming, nightmares type bad dreams Bad breath (halitosis) Milk products causes distress Sensitivity to hot water Burning or itching anus Craves sweets GROUP 6 Loss of taste for meat Lower bowel gas several hours after eating Burning stomach sensation, eating relieves Coated tongue Pass large amounts of foul-smelling gas Indigestion ½-1 hours after eating; may be up to 3-4 hours Mucous colitis or irritable bowel Gas shortly after eating Stomach bloated after eating pg. 5
GROUP 7 Insomnia Nervousness Intolerance to heat Highly emotional Flushes easily Night sweats Thin, moist skin Inward trembling Heart palpitates Increased appetite without weight gain Pulse fast at rest Eyelids and face twitch Irritable and restless Can t work under pressure GROUP 7B Increased weight gain Decreased in appetite Fatigue easily Ringing in ears Sleepy during the day Sensitive to cold Dry or scaly skin Constipation Mental sluggishness Hair course, falls out Headaches upon arising, wear off during the day Slow pulse, below 55 Frequency of urination Impaired hearing Reduced initiative GROUP 7C Failing memory Low blood pressure Increased sex drive Headaches, splitting or rending type Decreased sugar tolerance GROUP 7D Abnormal thirst Bloating of abdomen Weight gain around hips or waist Sex drive reduced or lacking Tendency to ulcers, colitis Increased sugar tolerance Women: menstrual disorder Young girls: lack of menstrual function GROUP 7E Dizziness Headaches Hot flashes Increased blood pressure Hair growth on face and body (female) Sugar in urine (not diabetes) Masculine tendencies (female) GROUP 7F Weakness, dizziness Chronic fatigue Low blood pressure Nails weak, ridged Tendency to hives Arthritis tendencies Perspiration increases Bowel disorder Poor circulation Swollen ankles Craves salt Brown spots or bronzing of skin Allergies tendency to asthma Weakness after colds, influenza Exhaustion muscular and nervous Respiratory disorders GROUP 8 Apprehension Irritability Morbid fears Never seems to get well Forgetfulness Indigestion Poor appetite Craving for sweets Muscular soreness Depression, feeling of dread Noise sensitivity Acoustic hallucinations Tendency to cry without reason Hair is course and/or thinning Weakness Fatigue Sin sensitive to touch Tendency towards hives Nervousness Headaches Insomnia Anxiety Anorexia Inability to concentrate, confusion Frequent stuffy nose, sinus infection Allergy to some foods Loose joints FEMALE ONLY Very easily fatigues Premenstrual tension Painful menses Depressed feeling before menstruation Menstruation excessive and prolonged Painful breasts Menstruate too frequently Vaginal discharge Hysterectomy / ovaries removed Menopausal hot flashes Menses scanty or misses Acne, worse at menses Depression of long standing MALE ONLY Prostate trouble Urination difficult or dribbling Night urination frequency Depression Pain on inside of legs or heels Feeling of incomplete bowel evacuation Lack of energy Migration aches and pains Tire too easily Avoids activity Legs nervousness at night Diminished sex drive
MEDICAL TOCXICITY QUESTIONNAIRE Please rate each of the following symptoms based upon your health profile for the last 3 months. Point Scale 0 - Never or almost never experience the symptom 1 - Occasionally experience it, effect is not severe 2 - Occasionally experience it, effect is severe 3 - Frequently experience it, effect is not severe 4 - Frequently experience it, effect is severe HEAD Headaches Faintness Dizziness Insomnia Total EYES Watery or itchy eyes Swollen, redness or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (does not include near- or far-sightedness Total EARS Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing loss Total NOSE Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation Total MOUTH/THROAT Chronic coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums, lips Canker sores Total SKIN Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating Total HEART Irregular or skipped heartbeats Rapid or pounding heartbeats Chest pain Total LUNGS Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing Total DIGESTIVE TRACT Nausea, vomiting Diarrhea Constipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach pain Anti-biotic use Total JOINT / MUSCLE Pain or aches in joint Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness Total WEIGHT Binge eating / drinking Cravings certain foods Excessive weight Compulsive eating Water retention Underweight Total ENGERY/ACTIVITY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness Total MIND Poor memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities Total EMOTIONS Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression Total OTHER Frequent illness Frequent or urgent urination Bladder Leakage Genital itch or discharge Total TOTAL, SECTION I:
SECTION II: RISK OF ENVIRONMENTAL EXPOSURE Point Scale 0 - Never 1 - Occasionally 2 - Monthly 3 Weekly 4 Daily 1. How often do you use pesticides in your home? 2. How often are strong chemicals used in your home? (bleach, over/drain cleaner, furniture polish, floor wax, window cleaner, disinfectant) 3. How often are you exposed to tobacco smoke, moth balls, incense, varnish, or dust? 4. How often do you treat your home for insects? 5. How often are you exposed to nail polish, perfumes, hair spray, or other cosmetics? 6. How often are you exposed to diesel fumes, exhaust fumes or gasoline fumes? Total _ Point Scale 0 None 1 Mild Change 2 Moderate Change 3 Drastic Change 1. Have you noticed any negative change in your health since you started your job? 2. Have you noticed any negative change in your health since you moved into your home or apartment? Total _ Circle the corresponding answer below, if any of them apply to you. Solvent Exposure: No Yes Painters, dry cleaners, construction workers, printers, office workers, acrylic nails, beauticians, automotive mechanics, truck drivers and others who spent time on the roads, including flight attendants. Applies to those who are sensitive to paints, glues, perfumes and more. Formaldehyde Relief: No Yes Individuals who are currently exposed to formaldehyde's in new carpet, new furniture cabinetry, upholstery fabric and floor covering, including medical students and physicians and mobile home and prefab home dwellers. Consider also in Candida overgrowth and those who consume alcohol regularly. Pesticide Protection: No Yes All individuals seem to register on some level of having some type of pesticides in their body. Pesticide exposure may result in narrow toxicity that can do damage to our nervous system and can significantly affect our immune system and endocrine (hormonal) system. This also including exposure to pesticides, such as lawn and garden chemicals, spraying in residential or workplace areas and traveling or living in agricultural spots. Individuals who are chemically sensitive, as well as those who've worked around pesticides and now have chronic health complaints. Heavy Metal Support: No Yes Heavy metals are a common underlying factor in many people who experience chemically overloads. This would include individuals going through heavy metal detoxification of lead, mercury, arsenic, and cadmium.