Client Intake and Health History Questionnaire

1

Sage Advice Naturopathic Care
Tanya McCoy, ND
22 North Road, Suite 202
Bloomingburg, NY 12721
(845)321-2040

Client Intake and Health History Questionnaire

PLEASE COMPLETE THE FOLLOWINGQUESTIONNAIRE AS THOROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON'T UNDERSTANDWITH A QUESTION MARK.

List your most important health problems in order of importance

1. ______

2. ______

3. ______

4. ______

5. ______

History of Health Condition(s):

When, where & from who did you last receive medical care or general health care?

______

What was the reason? ______
Did you get blood work?_____

What kind of blood work?______

Are you currently seeing a primary care physician?____Who?______

Please list any Diagnosed Conditions Doctor who diagnosed

1. ______

2. ______

3. ______

4. ______

5. ______

Family History: indicate if you or members of your close family have had the following:

Self Mother Father Brother(s) Sister(s) Grandparents(MGP) (PGP)

Cancer ______/__ ___/__

Diabetes ______/__ ___/__

Heart Disease ______/__ ___/__

High Blood Pressure ______/__ ___/__

Stroke ______/__ ___/__

Epilepsy ______/__ ___/__

Mental Illness ______/__ ___/__

Asthma/Allergies ______/__ ___/__

Anemia ______/__ ___/__

Kidney Disease ______/__ ___/__

Bowel Disease ______/__ ___/__

Ulcer ______/__ ___/__

Tuberculosis ______/__ ___/__

Osteoporosis ______/__ ___/__

Thyroid disease ______/__ ___/__

Age if living ______/__ ___/__

YourHealth History

What is your nationality/ethnicity?______Any known genetic risks ______

Did you have the following Disease (D), Immunized for it (I), or Neither (N):

Measles: D I N Diptheria: D I N

Mumps:D I NTetanus:D I N

Rubella:D I NWhooping Cough:D I N

Chickenpox:D I NHemophilus (Hib):D I N

German Measles: D I NHepatitis B: D I N

Any vaccination reactions:______

Please list all Hospitalizations and Surgeries including dates occurred:

1)______4) ______
2)______5) ______
3)______6) ______

X-Rays and Special Studies: X-rays, MRIs, CAT scans, EKGs or other studies you have had:

______

______
Please list any Accidents/Trauma including dates:______
______

Allergies/Sensitivities/Reactions
Medications/drugs?______

Environmental? ______

Any known food sensitivities or allergies?______

Current Medications:Circle Yes(Y) No(N) or Past (P) regarding use of the following:

Antacids:Y N PSteroids:Y N P

Smoking:Y N PPacks per day if Yes/Past:______

Pain relievers:Y N PLaxatives: Y N P

Antibiotics: Y N P Appetite Suppressants: Y N P

Sleeping Pills:Y N P Diuretics: Y N P

Cortisone: Y N P Anti-Depressants: Y N P

Please list all of the following that you have taken in the last 6 months.

Prescription medications:
______
______
______
Over the counter medications:
______
______

Vitamins and supplements:
______
______
______

Review Of Systems:

Present Height Weight:______lbs. Weight 1 year ago:______lbs.

Maximum Weight Date:______Desired weight: ______lbs.

REGARDING THE NEXT LONG SECTION: Please CircleY if you have the problem NOW,
if you’ve NEVER had the problem, P if you had the problem in the PAST.

Good Energy: Y N P

Fatigue: Y N P

If you have fatigue, when in morning, afternoon, evening is it the worst?:______

If you have fatigue, can you do what you need to during the day?: Y N

Skin:

Rash: Y N PColor Change: Y N P

Hives: Y N PLump: Y N P

Psoriasis/eczema: Y N PItchy: Y N P

Dry: Y N PWarts/moles: Y N P

Cancer: Y N PPerspiration: Y N P

Head:

Headache: Y N PMigraine: Y N P

Dandruff: Y N PHead Injury: Y N P

Oil/dry hair: Y N PHair loss: Y N P

Eyes:

Watery: Y N PBlurry vision: Y N P

Double vision: Y N PCataracts: Y N P

Glaucoma: Y N PStyes: Y N P

Strain: Y N PDischarge: Y N P

Itchy: Y N PDark under eyelid: Y N P
Glasses/contact lenses: Y N P Dryness: Y N P

Ears:

Ringing: Y N P Hearing loss: Y N P
Infections: Y N P Pain: Y N P

Nose:

Frequent colds: Y N PNosebleeds: Y N P

Congestion: Y N PPost nasal drip: Y N P

Polyps: Y N PSeasonal allergies: Y N P

Mouth/Throat:

Canker sores: Y N PCold sores: Y N P

Sore throat: Y N PGum disease: Y N P

Dentures: Y N PCavities: Y N P

Loss of taste: Y N PHoarseness: Y N P

Neck:

Stiffness: Y N PSwollen glands: Y N P

Full movement: Y N PTension: Y N P

Respiratory:

Cough: Y N PTB: Y N P

Shortness of breath with exertion: Y N PBronchitis: Y N P

Shortness of breath sitting: Y N PPneumonia: Y N P

Shortness of breath lying down: Y N PAsthma: Y N P

Wheezing: Y N PPainful breathing: Y N P

Cardiovascular:

High blood pressure:Y N PRheumatic Fever: Y N P

Low blood pressure:Y N PMurmurs: Y N P

Arrhythmias: Y N PPalpitations: Y N P

Edema:Y N PChest pain: Y N P

Gastrointestinal:

Heartburn:Y N PBowel movement frequency:______

Indigestion:Y N PRecent change in BM: Y N P

Bloating:Y N PDiarrhea or constipation: Y N P

Nausea:Y N PHemorrhoids: Y N P

Vomiting:Y N PGall bladder disease: Y N P

Change in Appetite:Y N PLiver disease: Y N P

Pancreatitis:Y N PUlcer: Y N P

Urinary Tract:

Incontinence:Y N PPain with urination: Y N P

Frequent infections:Y N PKidney stones: Y N P

Urgency:Y N PDischarge/blood: Y N P

Male Health:

Testicular pain/swelling: Y N PSexually active: Y N P

Hernia: Y N PSexually transmitted disease:Y N P

Discharge: Y N PProstate disease/symptoms: Y N P

Impotency: Y N PSexual orientation: Hetero Homo Bi

Female Health:

Age periods began:______How often periods occur:______

How long periods last: ______Menopausal since what age:______

Periods:Times Pregnant:______

Heavy Bleeding: Y N PHow many births:______

Cramping: Y N PMiscarriages:______

Pain: Y N PAbortions:______

PMS: Y N PSexual Active: Y N P

Food Cravings: Y N PHealthy Libido: Y N P

Last Pap Smear:______Pain With Intercourse: Y N P

Diagnosis: ______Dry Vagina: Y N P

Any abnormal paps: Y N PVaginitis: Y N P

When was abnormal: Y N P

Any Birth Control (please list types and ages used):______

Sexually Transmitted Diseases: Y N P Which?______
Dexa Scan: Y N P If Yes, what were the results:______
Use of Hormones: Y N P

Breasts:
Do you self exam? Y N P How often?______

Pain: Y N P Lumps: Y N P

Fibrocystic breasts: Y N P Lumpectomy: Y N P When?______

Premenstrual tenderness: Y N P Nipple discharge: Y N P

Recent Mammogram Y N When?______
Family history of breast/ovarian cancer Y N ______

Musculoskeletal:

Weakness: Y N PArthritis: Y N P

Stiffness: Y N PLeg cramps: Y N P

Tremors: Y N PPain:Y N P

Nervous:

Paralysis: Y N PSciatica: Y N P

Tingling/numbness:Y N PCarpal tunnel syndrome: Y N P

Seizures: Y N PFainting:Y N P

Mental/Emotional:

Depression:Y N PAnger/irritability: Y N P

Suicidal:Y N PHigh-strung/tense: Y N P

Anxiety:Y N PFear/Panic: Y N P

Habits and lifestyle:
Exercise:
How often:______

What type(s):______

For How long:______

Interests/Hobbies: ______

Sleep:

How long per night on average: ______

Do you wake up frequently?______What is the reason?: ______

Nightmares: Y N P

Wake refreshed:Y N P

Must Nap during the day: Y N P

Sleep walk: Y N P

Grind Teeth: Y N P

Snore: Y N P
When during the day is your energy the best? ______
Worst? ______

Food:

Appetite Good? Y N P

Foods crave: ______

Foods Dislike: ______

Foods that don’t sit well:______
Do you eat 3 square meals?______
How often do you eat out?______

Typical Daily Food Intake

Breakfast:______

Lunch: ______

Dinner:______

Snacks:______

Beverages:______
Which do you currently use?

Coffee: Y N PCups per day if Yes/Past:______

Soda Pop: Y N POunces per day if Yes/Past:______
Tea: Y N PCaffeinated Cups/day?______

Artificial Sweeteners: Y N P
Tobacco: Y N P Packs/day?______

Alcohol: Y N PHow often and how much if Yes/Past:______
Any alcohol addiction: Y N P

Any alcohol treatment: Y N P

Recreational drugs: Y N P

Any drugs addiction: Y N P

Any drug treatment: Y N P

Toxin Exposure:

Did you grow up near any refinery, or polluted area, or in home with leaded paint? If so, what sort of pollution were you exposed to?:______

Have you had any jobs where you were exposed to solvents, heavy metals, fumes, or other toxic materials?:______

Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets, or did other refurbishing?:______

Are you particularly sensitive to perfumes, gasoline, or other vapors?:______

Do you use pesticides, herbicides, other chemicals around your home?______

______

Work Life:
Current occupation: ______How many hours/week:______
Enjoy job?: Y N P
How often do you go on vacation?______
Personal Life:

Active Spiritual practice: Y N P If yes, what?______
What do you enjoy most in life?______
How much time do you spend outside?______Do you enjoy time outside?______
How many hours per week do you watch television?______

Quality of most significant relationship?______
Do you feel supported in your current relationship?______

History of sexual, mental/emotional, physical abuse?: Y N

If so, at what age and by whom?: ______

What is your greatest health concern?______
How does your health concern(s) affect your life?______How committed are you towards making valuable changes: Little Moderately Very
Which of the following would you like included in your health plan if appropriate?

Dietary recommendations______Stress management _____
Exercise ______

Vitamins/Minerals______Other nutrients_____ Herbs _____ Homeopathy____ Hydrotherapy_____

What do you think is the most important part of your healing process?______