Adult Intake Form Last Name: First Name: Date: Address: City: State Zip Telephone (Home): Telephone (Work): Email Address: Age: Date of Birth: Gender: Married: Separated: Divorced: Widowed: Single: Partnership: Live with: Spouse Partner Parents: Children: Friends: Alone: Do you have any children? Y / N if yes please list their ages: Occupation: Hours per Week: Employer name and address: In an emergency contact: Ph: How did you hear about this clinic/referred by? If internet: Google AANP website WANP website Other: Emergency Contact: Relationship: Phone: Address: Have you ever consulted a Naturopathic physician before? Y / N Are you currently receiving healthcare? Y / N, if yes where and from whom?: What was the reason? Present Health Concerns: Please list important health concerns in their order of significance. 1. 2. 3. 4. Page 1
5. What do you believe is causing your most important health concerns? What goals do you have for your visit today? Do you have any contagious diseases at this time? Y / N If yes, what? Past Medical History: Hospitalizations/Surgeries/injuries: Year: Year: Year: Year: Allergies: Please include mild to severe or life-threatening allergies and reactions (symptoms) 1.)Medications: 2.)Food: 3.)Environment: General: Height: Weight: Weight 1 year ago: Maximum Weight: When: When during the day is your energy best? Worst? Page 2
Main interest and hobbies: Exercise: Y / N If so, what kind and how often: Watch T.V.: Y / N If yes, how many hours? Read: Y / N If so, how many hours? Do you have any religious or spiritual practices? Y / N If so what kind? Diet: Breakfast: Lunch: Dinner: Snacks between meals: How many glasses of water do you drink each day on average?: What other beverages do you drink and how much per day? Personal Habits: Coffee? Y/ N If yes how often and how much? Drink alcohol? Y / N If yes how often and how much? Smoke? Y / N If yes, how often and how much? Recreational drugs? Y / N if yes, what, how often and how much? Sexual History: Are you sexually active? Y / N If yes, with: Men Women Both Are you practicing safer sex methods? Y /N What form of contraception/ Birth control are you using? (Please check all that apply) Abstinence Withdrawal Fertility awareness method The sponge Spermicide Condom Diaphram Cervical cap IUD(circle copper/periguard or merena) The pill The Depo shot Nuvaring Implants The patch Vasectomy None If yes, is the current form working for you? Y / N, If current or past problems please describe briefly: Labs and Exam History: Date of last full physical exam: Results: Normal Other Date of last blood work: Results: Normal Other Date of last urine test: Results: Normal Other Date of last PAP and pelvic exam: Results: Normal Other Date of last mammogram: Results: Normal Other Date of last DEXA scan: Results: Normal Other Page 3
PERSONAL and FAMILY HISTORY: Please place a C for current or P for past in the box as it applies to you or your family members. Self Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Alcoholism Allergies Anemia Arthritis Asthma Cancer Depression Diabetes Drug Addiction Eczema Epilepsy Headaches Heart Disease Hepatitis High Blood Pressure Kidney Disease Mental Illness Stroke Tuberculosis Sleep: How many hours of sleep do you get a night on average? How often do you wake and for what reasons?: Do you have any trouble falling asleep? Y / N If yes, why? Do you have any trouble waking up? Y / N If yes, why? ENERGY AND STRESS: How would you rate your energy on a scale of 1 10 with 10 being the most energy? How would you rate your stress on a scale of 1 10 with 10 being the most stress? How do you cope with stress? TRAVEL HISTORY: Identify any domestic or foreign travel and indicate year of travel: Page 4
Place: Year: Place: Year: Place: Year: Place: Year: Place: Year: Place: Year: Place: Year: Place: Year: IMMUNIZATIONS: Please place an X in either the Yes or No box next to each vaccination that you have been vaccinated against. If Yes, please indicate whether there were any reactions and describe in detail. Hepatitis B Immunization No Yes Reaction Description Diphtheria, Tetanus, Pertussis(DPT) Haemophilus Influenza Type B Inactivated Polio Measles, Mumps, Rubella(MMR) Varicella (Chickenpox) Pneumococcal Influenza Rotavirus Human Papilloma Virus (HPV) Pharmacy name: Pharmacy ph:( ) Medication Log Please list prescription medications +/or over the counter medications that you are currently taking, with dosages Rx Name Reason for Rx Dosing Start Date Stop Date Page 5
Supplement Log Please list vitamins, minerals, herbs, homeopathic remedies that you are currently taking, with dosages Supplement name Reason for Supplement Dosing Start date Stop date For the following, please mark: Y= a condition you have now, N=never had, P= a significant problem in the past, S=sometimes a problem GENERAL IMMUNE Do you sleep well? Reactions to immunizations Average 6 to 8 hours? Chronically swollen glands Awake rested? Slow wound healing Page 6
Have a supportive relationship Have a history of abuse Chronic Fatigue Syndrome Night sweats Experience a major trauma? Treated for drug dependence? Do you enjoy your work? Take vacations? Spend time outside? EARS Impaired hearing Ringing in ears Dizziness Ear aches Eat three meals a day? EYES Do you go on diets often? Impaired vision Do you go out often Glaucoma Drink black/green tea? Cataracts Drink soda? Eye pain or strain Do you eat refined sugar? Spots in vision Do you add salt to your food? Color blindness ENDOCRINE Tearing or dryness Difficulty exercising MOUTH AND THROAT Seasonal depression Frequent sore throat Excessive hunger Copious saliva Diabetes Sore tongue or lips Heat or cold intolerance Hoarseness Hypoglycemic Jaw clicks Hypothyroid Teeth grinding Hyperthyroid Gum problems Excessive thirst Dental cavities Fatigue SKIN NEUROLOGIC Rashes Page 7
Seizures Acne/boils Muscle weakness Changes in skin color Loss of memory Lumps or bumps on skin Vertigo or dizziness Eczema or hives Paralysis Itching Numbness or tingling Perpetual hair loss Easily stressed NOSE AND SINUS Loss of balance Frequent colds HEAD Stuffiness Headaches Sinus problems Migraines Nose bleeds Head injury Hay fever Jaw or TMJ problems Loss of smell RESPIRATORY NECK Cough Lumps in neck Sputum Goiter Asthma Difficulty swallowing Wheezing Pain or stiffness in neck Bronchitis BLOOD Coughing up blood Easy bleeding or bruising Shortness of breath Anemia Shortness of breath lying down Cold hands/feet Pain in breathing Deep leg pain Emphysema Thrombophlebitis Tuberculosis Varicose veins GASTROINTESTINAL MENTAL/EMOTIONAL Trouble swallowing Treated for emotional problems Change in thirst Depression Page 8
Change in appetite Anxiety or nervousness Nausea/vomiting Poor concentration Ulcer Do you have mood swings? Jaundice Considered suicide? Gall baldder disease Attempted suicide? Liver disease Tension Hemorrhoids Memory problems Pancreatitis URINARY Heartburn Increased frequency of urination Abdominal pain or cramps Inability to hold urine Belching or passing gas Pain in urination Constipation Frequency at night Bowel movements: How often? Frequent UTI s Is this a change? Kidney stones Black stools MUSCULOSKELETAL Blood in stools Joint pain or stiffness FEMALE REPRODUCTIVE Arthritis Age of first menses Broken bones Age of last menses (if menopausal) Weakness Length of cycle days Muscle spasm or cramps Duration of menses days Sciatica Are your cycles regular MALE REPRODUCTIVE Painful menses Discharge or soreness Heavy or excessive flow Chlamydia PMS Gonorrhea Symptoms Genital warts Bleeding between cycles Herpes Clotting Syphilis Page 9
Endometriosis Hernias Ovarian cysts Testicular masses Gonorrhea Testicular pain Chlamydia Impotence Syphilis Premature ejaculation Vaginal odor FEMALE REPRODUCTIVE CONTINUED Discharge Number of pregnancies Date of last pap smear Number of live births Abnormal pap Number of miscarriages Cervical dysplasia Number of abortions Pain during intercourse Do you do self breast exams? Herpes Breast pain/tenderness Genital warts Breast lumps Currently trying to conceive Nipple discharge Difficulty conceiving Menopausal symptoms Any chance you may be pregnant Signature: Date: / / Page 10