NEW PATIENT INFORMATION *All information provided is kept in strict confidence

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Transcription:

NEW PATIENT INFORMATION *All information provided is kept in strict confidence Name: Date: Address: Telephone: (home) (cell) (work) E-mail: Emergency contact: (name) (relationship) telephone: (home) (cell) Primary care physician: (name) (telephone) Address: Referred by: Occupation: Date of Birth: Age: Sex: male female Weight: Height: Marital Status: single married divorced widowed Number of children, if any: Number of pregnancies: Female Patients: Age at first period: P. 1 of 6

Main concerns, in the order of priority, and date started: Can you trace the origin of any present condition to any particular circumstance? (e.g. accident, illness, grief, mental upset, etc.) Prescription medications, non-prescription medications and health supplements you are currently taking: Name Dosage Condition treated Since when Other treatments or therapies: Name Frequency Since when Substances you are using: Description Amount Description Amount Alcohol Chewing Tobacco Cigarettes Coffee Laxatives / Purgatives Pain Killers Recreational Drugs Sleeping Pills Tea Other Allergies: P. 2 of 6

Medical history Medical procedures, surgeries, hospitalizations, accidents and major trauma Date Description Vaccinations: Measles Mumps Rubella Pertussis Chicken Pox Flu Other Adverse reactions: Which of the following have you experienced or are you suffering from now: Abortion Diabetes Hypertension Measles Rheumatic Fever Verenial warts Alcoholism Eczema Hepatitis Mental problems Sexual Abuse Warts Allergies Epilepsy Herpes Miscarriage Skin Disease Whooping Cough Anemia Emphysema Influenza Mononucleosis Strep Throat Worms Appendicitis Gall Stones Jaundice Mumps Sinusitis Yellow Fever Asthma Goitre Kidney Disease Nosebleeds Stroke Cancer Gonorrhoea Pneumonia Parasites Syphilis Other: Chicken Pox Gout Leukaemia Tonsillitis Thyroid problems Cold Sores Hay Fever Liver Disease Prostatitis Tuberculosis Depression Heart Trouble Malaria Psoriasis Urticaria Your mother s pregnancy give details about: Problems Drugs Difficulty about your birth? P. 3 of 6

Family history: Ailments which may be present in your family history: Alzheimer s Diabetes Hypertension Mental problems Tuberculosis Alcoholism Depression Heart Disease Skin Disease Cancer Gonorrhoea Hepatitis Syphilis Relationship Age Diseases Age at death Mother Father Cause of death Brother(s) Sister(s) Children Maternal Grandmother Grandfather Aunts Uncles Paternal Grandmother Grandfather Aunts Uncles P. 4 of 6

Details about your Symptoms: What triggers your symptoms (mental, emotional and physical symptoms)? Does anything make your symptoms unique? What makes your symptoms better (i.e. hot/cold, eating, sleep, time of day)? What makes your symptoms worse? Are you affected by the weather? How? Perspiration (odour, night sweats, profuse)? Body temperature: Sleep (falling asleep, waking, position): Average energy level during the day (0 = none, 10 = max.): Have you lost any weight recently? How much? Are there any themes running through your life, e.g. all my life..? P. 5 of 6

Is there anything else regarding your overall condition that we should know? Do you give permission to share your information with your other health care providers for purposes of medical evaluation? yes no Would you like to receive periodic information on specials? yes no (signature) How did you hear about K-W Homeopathic Medicine and Wellness Clinic? Referral from Health Care Practitioner Internet Referral from family or friends Newspaper Public Health Talk Magazine St. Jacobs Farmers Market Event Other Thank you for taking the time to fill out this form! P. 6 of 6

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