Natural Healing Family Medicine
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- Peregrine Thomas
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1 Adult Intake Form Last Name: First Name: Date: Address: City: State Zip Telephone (Home): Telephone (Work): 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 Page 1
2 4. 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: Page 2
3 General: Height: Weight: Weight 1 year ago: Maximum Weight: When: When during the day is your energy best? Worst? 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: Page 3
4 Labs and Exam History: Date of last full physical exam: Date of last blood work: Date of last urine test: Date of last PAP and pelvic exam: Date of last mammogram: Date of last DEXA scan: 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 Page 4
5 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: 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 Diphtheria, Tetanus, Pertussis(DPT) Haemophilus Influenza Type B Inactivated Polio Measles, Mumps, Rubella(MMR) Varicella (Chickenpox) Pneumococcal Influenza Rotavirus Human Papilloma Virus (HPV) No Yes Reaction Description Page 5
6 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 Last name: First name: Date of birth: 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 Page 6
7 For the following, please circle: Y= a condition you have now, N=never had, P= a significant problem in the past, S=sometimes a problem General: Do you sleep well? Y N P S Average 6 to 8 hours? Y N P S Awake rested? Y N P S Have a supportive relationship? Y N P S Have a history of abuse? Y N P S Experience a major trauma? Y N P S Treated for drug dependence? Y N P S Do you enjoy your work? Y N P S Take Vacations? Y N P S Spend time outside? Y N P S Eat three meals a day? Y N P S Do you go on diets often? Y N P S Do you eat out often? Y N P S Drink black/green tea? Y N P S Drink soda? Y N P S Do you eat refined sugar? Y N P S Do you add salt to your food? Y N P S Endocrine Hypothyroid? Y N P S Hyperthyroid Y N P S Endocrine Cont. Diabetes? Y N P S Excessive hunger? Y N P S Seasonal Depression? Y N P S Difficulty Exercising? Y N P S Immune Reaction to immunizations? Y N P S Chronically swollen glands? Y N P S Slow wound healing? Y N P S Chronic fatigue syndrome? Y N P S Night sweats? Y N P S Ears Impaired hearing? Y N P S Ringing in ears? Y N P S Dizziness? Y N P S Ear Aches? Y N P S Eyes Impaired vision? Y N P S Cataracts? Y N P S Glaucoma Y N P S Eye pain or strain Y N P S Hypoglycemic? Y N P S Heat or cold intolerance Y N P S Spots in vision? Y N P S Excessive thirst? Y N P S Hyperthyroid Y N P S Fatigue? Y N P S Color blindness? Y N P S Tearing or dryness? Y N P S Page 7
8 Neurologic Seizures? Y N P S Muscle weakness? Y N P S Loss of memory? Y N P S Vertigo or dizziness? Y N P S Paralysis? Y N P S Numbness or tingling? Y N P S Easily stressed? Y N P S Loss of balance? Y N P S Head Headaches? Y N P S Migraines? Y N P S Head injury? Y N P S Jaw or TMJ problems? Y N P S Nose and Sinus Frequent colds? Y N P S Stuffiness? Y N P S Sinus problems? Y N P S Nose bleeds? Y N P S Hayfever? Y N P S Loss of smell? Y N P S Neck Lumps in neck? Y N P S Goiter? Y N P S Difficulty swallowing? Y N P S Pain or stiffiness in neck? Y N P S Mouth and Throat Frequent sore throat? Y N P S Copious saliva? Y N P S Sore tongue or lips? Y N P S Hoarseness? Y N P S Jaw clicks? Y N P S Teeth grinding? Y N P S Gum problems? Y N P S Dental cavities? Y N P S Skin Rashes? Y N P S Acne/boils? Y N P S Change in skin color? Y N P S Lumps or bumps on skin? Y N P S Eczema or hives? Y N P S Itching? Y N P S Perpetual hair loss? Y N P S Respiratory Cough? Y N P S Sputum? Y N P S Asthma? Y N P S Wheezing? Y N P S Bronchitis? Y N P S Coughing up blood? Y N P S Shortness of breath? Y N P S Shortness of breath when lying down? Y N P S Page 8
9 Respiratory cont. Pain in breathing? Y N P S Emphysema? Y N P S Tuberculosis? Y N P S Gasterointestinal Trouble swallowing? Y N P S Change in thirst? Y N P S Change in appetite? Y N P S Nausea/vomiting? Y N P S Ulcer? Y N P S Jaundice? Y N P S Gall bladder disease? Y N P S Liver disease? Y N P S Hemorroids? Y N P S Pancreatitis? Y N P S Heartburn? Y N P S Abdominal pain or cramps? Y N P S Belching or passing gas? Y N P S Constipation? Y N P S Bowel movements: How often? Is this a change? Black stools? Y N P S Blood in stools? Y N P S Mental/ Emotional Treated for emotional problem? Y N P S Depression? Y N P S Mental/ Emotional Cont. Anxiety or nervousness? Y N P S Poor concentration? Y N P S Do you have mood swings? Y N P S Considered suicide? Y N P S Attempted suicide? Y N P S Tension? Y N P S Memory problems? Y N P S Urinary Increased frequency of urination? Y N P S Inability to hold urine? Y N P S Pain in urination? Y N P S Frequency at night? Y N P S Frequent UTIs? Y N P S Kindey stones? Y N P S Musculoskeletal Joint pain or stiffness? Y N P S Arthritis? Y N P S Broken bones? Y N P S Weakness? Y N P S Muscle spasm or cramps? Y N P S Sciatica? Y N P S Blood Easy bleeding or bruising? Y N P S Anemia? Y N P S Cold hands/feet? Y N P S Page 9
10 Blood cont. Deep leg pain? Y N P S Thrombophlebitis? Y N P S Varicose veins? Y N P S Female Reproductive Age of first menses? Age of last menses? ( if menopausal) Length of cycle: days Duration of menses: days Are your cycles regular? Y N P S Painful menses? Y N P S Heavy or excessive flow? Y N P S PMS? Y N P S Symptoms: Bleeding between cycles? Y N P S Clotting? Y N P S Female Reproductive cont. Gonorrhea? Y N P S Chlamydia? Y N P S Syphilis? Y N P S Currently trying to conceive? Y N P S Difficulty conceiving? Y N P S Any chance you may be pregnant? Y N P S Number of pregnancies? Number of live births? Number of miscarriages? Number of abortions? Do you do self breast exams? Y N P S Breast pain/tenderness? Y N P S Breast lumps? Y N P S Nipple discharge? Y N P S Menopausal symptoms? Y N P S Male Reproductive Endometriosis? Y N P S Discharge or sores? Y N P S Ovarian cysts? Y N P S Vaginal odor? Y N P S Discharge? Y N P S Date of last PAP smear? Abnormal PAP? Y N P S Cervical Dysplasia? Y N P S Pain during intercourse? Y N P S Herpes? Y N P S Genital warts? Y N P S Chlamydia? Y N P S Gonorrhea? Y N P S Genital warts? Y N P S Herpes? Y N P S Syphilis? Y N P S Hernias? Y N P S Testicular masses? Y N P S Testicular pain? Y N P S Impotence? Y N P S Premature ejaculation? Y N P S Page 10
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ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message?
ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message? Age Date of Birth Gender Identity Relationship: Single
(PLEASE CIRCLE YES ANSWERS ONLY)
(PLEASE CIRCLE YES ANSWERS ONLY) Childhood Illnesses Scarlet Fever Y N Diphtheria Y N Rheumatic fever Y N Mumps Y N Measles Y N German Measles Y N Hospitalizations and Surgery What hospitalizations or
ADULT INTAKE. Name: Date: Address: City: Prov: PC: Telephone (home): (work): Age: Date of Birth: Gender: Female / Male
ADULT INTAKE Name: Date: Address: City: Prov: PC: Telephone (home): (work): Age: Date of Birth: Gender: Female / Male Married: Separated: Divorced: Widowed: Single: Partnership: Live with: Spouse: Partner:
(Work address): How did you hear about our clinic? Has any other family member already been a patient at the clinic?
Name: Date: Address: City: State: Zip Code: Telephone # (home): (work): E-mail address: Age: Date of Birth: Gender: female male Education: Married: Separated: Divorced: Widowed: Single:_ Partnership:_
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