In addition to the clinic forms, please answer the following questions so that Dr. Reddeman can accurately assess you.

Circle if you currently use:

1601 116th Avenue NE · Suite 100 · Bellevue WA 98004 · 425-451-0999

Laxatives

Heart medication

Birth control pills

Antibiotics

Anti-depressants

Cortisone

Sleeping pills

Antacids

Thyroid medication

Pain relievers

Allergy medicine

Hormones

1601 116th Avenue NE · Suite 100 · Bellevue WA 98004 · 425-451-0999

Circle if you have had any of the following childhood diseases:

Measles Mumps German measles Diphtheria Scarlet fever Rheumatic fever

List hospitalizations, surgeries, x-rays or other imaging you have had and year performed:

Family History*

Father / Mother / Brothers / Sisters / Children / Maternal Grandparents / Paternal Grandparents
Age (if living)
Current Health
Age at death
Cause of death

*Include if any of your family members have had the following: cancer, heart disease, diabetes, high blood pressure, epilepsy, stroke, anemia, allergies, arthritis, kidney disease, asthma, tuberculosis, glaucoma, mental illness or Alzheimer’s disease.

Please check if you have or do:

1601 116th Avenue NE · Suite 100 · Bellevue WA 98004 · 425-451-0999

___Exercise

Type______

Frequency ______Average 6-8 hrs. of sleep ___Have a supportive relationship ___History of abuse

___Major traumas

___Use recreational drugs

___Treated for drug abuse

/dependence

___Drink coffee

___Drink black or green tea

___Drink soda

___Add salt to your food

___Eat refined sugar

___Enjoy your work

___Watch TV

Amount ______

___Read

Frequency ______

___Use alcoholic beverages

# per week _____

___Treated for alcoholism

___Use tobacco currently

___Used tobacco in the past

Number of years ______

Packs per day______Have a spiritual practice

___Take vacations

___Spend time outside

1601 116th Avenue NE · Suite 100 · Bellevue WA 98004 · 425-451-0999

Context of Care

Welcome to Red Cedar Wellness. Whether you are here for a brief time or for longer-term health care, I look forward to learning how to help you. Please answer the following questions that will help me understand more about your health goals and hopes for your visits.

A. How did you learn about Red Cedar Wellness and what brings you in at this time?

B. What is your level of commitment to addressing any underlying causes of your current state of health that may relate to your life habits? Rate from 0 to 10 with 10 meaning that you are 100% committed.

0% 1 2 3 4 5 6 7 8 9 10 100%

If you are not 100% committed, what would help you get to 100%?

What gets in the way of 100% commitment to your health?

C. What regular habits do you currently have that you believe support or move you towards health and well-being?

D. What do you love most about your life right now?

E. What habits do you currently engage in that you would like to change?

F. What potential challenges do you anticipate in making the changes you desire or implementing recommendations I may make?

G. What are your top 3 expectations of me?

1.

2.

3.

1601 116th Avenue NE · Suite 100 · Bellevue WA 98004 · 425-451-0999