DATE
Last Name: First Name:
Birth date: Sex/Gender:
Address: ______Apt: ___
City: ______State: ______Zip: ______
Home Phone: ______Work Phone:______Cell phone
(which is best to reach you at? IS it OK to leave a message?)
Email address:
Mother and Father Name s (minors only): ______
Emergency Contact and phone number: ______
Married Single Significant Other Do you have children? Ages:
Insurance______Phone______Group # ID#
It is your responsibility to know the extent of your insurance coverage and copays if applicable.
Present Health Concerns: For chronic, or long standing health conditions, please make a “timeline”, including important dates, medications, outcomes etc…
Please list most important health concerns in their order of significance. / Prior diagnosis of this problem? If so, what? / Indicate painful or distressed areas:1.
2.
3.
4.
5.
Have you ever consulted a Naturopathic physician, an Acupuncturist, a Nutritionist or a Homeopath before?
Please list prescription medications that you are currently taking, with dosages:
1. 2. 3.
4. 5. 6.
List vitamins, minerals, herbs, homeopathic remedies that you are currently taking, with dosages:
1. 2. 3.
4. 5. 6.
Please list any severe or life-threatening allergies (drug, food, environmental): :
Hospitalizations:
Where did you grow up? Where have you lived in the past?
Serious Illnesses and Injuries:
Date of last physical/annual exam
Who is your Primary Care Physician? Phone and fax #
HEALTH SCREENING HISTORY: List the date of your most recent test or exam.
Mammogram ____ Pap Smear_____ Self Breast Exam ______Breast Exam by Professional ______
Self Testicle Exam _____ Testicle Exam by Professional______Prostate Exam by Professional ______
Test for Blood in stool ______Rectal Exam ______Scope of Lower Bowel (if over age 50)______
Blood tests: Cholesterol ______Blood Sugar ______Other Blood Tests______
Personal and Family History:
Please check the “yes” box next to each condition that applies to you or one of your family members. Please note whether condition applied to family member in the past or currently by denoting a “P” for past or “C” for current. Indicate the relationship or the word “self” in the “Relationship” column.
YES / RELATION / DATES RESOLVED Past(P)/Current(C) / YES / RELATION / DATES RESOLVED Past(P)/Current(C)Alcoholism/Drug Addiction / Headaches
Allergies / Heart Disease
Anemia / Hepatitis
Arthritis / High Blood Pressure
Asthma / Kidney Disease
Cancer / Mental Illness
Depression / Stroke
Diabetes / Tuberculosis
Eczema / Lyme Disease
Epilepsy / Other
SLEEP: Hrs of sleep____ Fall asleep O.K?____ Sleep through night? ____Wake rested? ______
What awakens you?______
WORK: Hr/wk you work ____ Do you enjoy work?___ What do you do?______
Hr/day commute_____ Employer______
EXERCISE: Regularly?____Wha type?______How long/often?______
DIET? ______How many meals a day? ______
Are you satisfied with your diet? _____ Cravings? ______
Breakfast:______
Lunch: ______
Dinner: ______
Snacks: ______
Alcohol______Caffeine (coffee, black tea, soda) ______Tobacco______
Recreational Drugs ______
LEISURE: activities/hobbies______
REVIEW OF SYSTEMS (C= you have now: P= you had in past)
Height______Weight ______Maximum Weight ______When?______Easy Weight Gain? ____
Length of time for weight gain/loss if you are over/underweight?______
GENERAL: Night sweats____ Fatigue____ Do you tend to feel more cold/hot?______
SKIN: Rashes ____ Hives______Psoriasis_____Eczema____Warts______Infection____ Growths Hair/Nail Changes_____ Other______
HEAD: Headaches____ Head Injury____ Other______
EYES: Impaired vision______Eye Pain____ Tearing/Dryness____Double Vision_____
Poor night vision____ Floaters____ Loss of vision____ Other______
EARS,NOSE,SINUS:FrequentColds______Dizziness______Ringing______Earache______Nse Bleeds______Stuffiness______
Sinus Problems______Post Nasal Drip______Other______
MOUTH, THROAT: Frequent Sore Throat______Sore Tongue______Gum Problems______
Dental Problems____Cavities/fillings______Sores in mouth/on lips____ Teething Grinding______Hoarseness______Other______
RESPIRATORY: Cough____ Spitting up Blood____ Wheezing____ Difficulty Breathing______
Pain on Breathing_____ Shortness of Breath____ When?(night, lying down, etc)______
Mucus ______Other______
HEART/CIRCULATION: Heart Disease_____ High Cholesterol____ High Blood Pressure_____ Chest Pain _____ Swelling in Ankles_____ Palpitations/Fluttering_____ Deep Leg Pain____
Cold Hands/Feet____ Varicose Veins____ Heart Murmur _____ Other______
DIGESTION: Change in Thirst_____ Change in appetite_____ Trouble Swallowing_____ Heartburn_____ Stomach Pain_____ Nausea_____ Vomiting_____ Loose Stools_____ Gas_____ Burping____ Bloating____ How many bowel movements per day? ____ Is this a change?______Blood in Stools____ Hemorrhoids____ Fissure____ Liver or Gall Bladder Disease ______
Anal discomfort _____ Other______
URINARY: Pain on Urination______Increased Frequency or urgency____ Frequency at Night____
Inability to Hold Urine____ Bladder Infections____ Other______
NEUROLOGICAL: Fainting ____ Seizures____ Paralysis_____ Muscle Weakness____ Numbness or Tingling____ Loss of Concentration/ Memory____ Coordination problem_____ Other______
HORMONAL: Thyroid issues____ Diabetes______Heat/Cold Intolerance____ Hypoglycemia____ Other______
BLOOD/ LYMPH: Anemia____ Easy Bleeding or Bruising____ Swollen Glands ____ Other______
EMOTIONAL Depression____ Mood Swings____ Anxiousness or Nervousness___ Tension___ Anger/Irritability____ Indecisiveness____ Family History______Other______
FEMALE REPRODUCTION: Age Menses Began____ Length of Complete Cycle ____
Date of Last Menstrual Period______ndometriosis_____Excessive facial or body hair_____
Number of Days Menstrual Flow____ Bleeding Between Periods____ Excessive Flow____
Are Cycles Regular____ Cramps____ Premenstrual Symptoms:______
Abnormal Vaginal Discharge or drynesss____ Date of Last Pap Smear____ Abnormal Pap Smears? ____
Number of Pregnancies____ Number of Live Births____ Number of Miscarriages____
Sexually Active (men, woman, both)____ Birth Control____(Type ______) Pain During Intercourse_____
Sexual Difficulties____ Difficulty Conceiving____ Venereal Disease______
Number of Abortions_____(Optional) Sexual Orientation: ______(Optional)
Menopausal Symptoms______
Regular Self-Breast Exam____ Lumps____ Pain/Tenderness____ Nipple Discharge____
MALE REPRODUCTION Regular Self-Testicular Exam?____ Testicular Mass____ Testicular Pain____ Sexually Active ______Sexual Difficulties____ Prostrate Problems____ Venereal Disease____ Sores ____ Discharge____ Difficulty Urinating______
Birth Control ____ (Type ______) Sexual Orientation______(Optional)
MUSCULOSKELTAL:
Joint Pain/Stiffness____ Morning stiffness____ (lasts how long?______) Broken Bones____
Hernias ____ Weakness____ Restless Leg_____Motor Vehicle Accidents______
Indicate any problem areas on diagram below:
IF NOT NOTED ABOVE IT IS NEGATIVE, NON-CONTRIBUTORY, AND/OR NON-PERTINANT
I certify that the information that I have supplied is correct and accurate to the best of my knowledge.
Printed Name ______Date ______
Signature______Relationship to Patient: ______
How did you hear about me? Newspaper? Mailer/Flyer Website Workshop/Event Medical Referral Friend/Family Insurance Co. Other: