Naturopathic Intake Paperwork
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- Ross Joseph
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1 3500 Kensington Ave Suite B- 2 Richmond, VA T/F Naturopathic Intake Paperwork 1) What led you to choosing this clinic? 2) What do you know about us and how we work? 3) What three expectations do you have from today s visit at our clinic? 4) What three long- term expectations do you have from working with our clinic? 5) At this present time, how committed are you to addressing the underlying causes of your signs and symptoms that may relate to your lifestyle? (0= not committed and 10= completely committed). Please circle ) What types of daily or weekly lifestyle habits do you feel support or strengthen your health? 7) What types of daily or weekly lifestyle habits do you feel do not fully support your health? 8) What obstacles or challenges do you potentially anticipate that may undermine your health and following through on your treatment? 9) Who do you know that will sincerely support you consistently with the lifestyle change you will be making to regain your health and vitality?
2 10) What do you love doing; what brings you joy? 11) Wellness is achieved through various aspects of our lives. Using this pie chart, please shade your level of satisfaction of each area. Start shading from the center out to the edge of the circle. For example if you are 50% satisfied in your career you will shade starting from the center out and fill in half of that section of the pie chart (5 rings or bands). If you are 100% satisfied in your financial/money then shade all 10 bands or rings on the chart. Physical Environment Career Family & Friends Money Personal Growth Health FAMILY HISTORY Fun & Recreation Significant Other/ Romance Do you have a family history of any of the following (please check all that apply)? Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Epilepsy Arthritis Glaucoma Tuberculosis Stroke Anemia Mental Health Illness Asthma Hay Fever Hives Any other relevant family history? CHILDHOOD ILLNESSES Which of the following have you had as a child? Scarlet fever Diphtheria Rheumatic fever Mumps Measles German measles Chicken pox Shingles 2
3 HOSPITALIZATIONS, SURGERIES, IMAGING What hospitalizations, surgeries, X- Rays, CAT Scans, EEG, EKG s have you had? _Year Year Year Year_ ALLERGIES Any drugs? Any foods? Any environmental or chemical products? CURRENT MEDICATIONS Do you take or use? Laxatives Yes No Pain relievers Yes No Antacids Yes No Cortisone Yes No Appetite suppressants Yes No Thyroid meds Yes No Antibiotics Yes No Anti- depressants Yes No Sleeping pills Yes No Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking (including herbs)? 1) 6) 2) 7) 3) 8) 4) 9) GENERAL INFORMATION Height: Weight: lbs. Weight 1 year ago: lbs. Maximum Weight ever: When was this: Blood Type (if known): When during the day is your energy the best? Worst? FOOD Please the most typical foods you eat for each meal. Breakfast: Lunch: Dinner: Snacks: To drink: 3
4 LIFESTYLE For this section, PLEASE CIRCLE Y=Yes (a condition you have now), N=No (never had) and P= in the Past (significant problem of past). Main interests or hobbies: Do you exercise? Y N If so, what kind and how often? Do you get an average of 6-8 hrs. of sleep? Y N Do you enjoy your work? Y N Sleep well? Y N Do you take vacations? Y N Awaken rested? Y N Do you spend time outside? Y N Do you have a supportive relationship(s)? Y N Do you have a history of abuse? Y N How many hours do you watch TV? Any major traumas? Y N P Use alcoholic beverages? Y N P Treated for drug dependence? Y N P Use recreational drugs? Y N P Treated for alcoholism? Y N P Do you eat 3 meals a day? Y N P Do you go on diets often? Y N P Do you drink coffee? Y N P Do you drink cola/other sodas? Y N P Do you currently use tobacco? Y N P Do you have a spiritual practice? Y N P - If yes, what? - If yes, what? REVIEW OF SYSTEMS MENTAL/EMOTIONAL Depression? Y N P Anxiety or nervousness? Y N P Mood Swings? Y N P Tension? Y N P Considered/Attempted suicide? Y N P Poor concentration? Y N P Concerns about memory? Y N P Memory problems? Y N P Are you in physical pain? Y N P Rate your pain on 0-10 scale Rate your stress level on a scale of 0-10: Sources of stress: What practices do you have for stress management? _ IMMUNE SYSTEM Reactions to vaccinations? Y N P Autoimmune? Y N P Chronic Fatigue Syndrome? Y N P Chronic infections? Y N P Chronically swollen glands? Y N P Slow healing? Y N P ENDOCRINE Hypothyroid? Y N P Heat or cold intolerance? Y N P Hypoglycemia? Y N P Diabetes? Y N P Excessive thirst? Y N P Excessive hunger? Y N P Fatigue? Y N P Seasonal depression? Y N P NEUROLOGICAL Seizures? Y N P Paralysis? Y N P Muscle weakness? Y N P Numbness or tingling? Y N P Loss of memory? Y N P Easily stressed? Y N P Vertigo or dizziness? Y N P Loss of balance? Y N P 4
5 SKIN Rashes? Y N P Eczema, Hives? Y N P Acne, Boils? Y N P Itching? Y N P Color Change? Y N P Hair Loss? Y N P Lumps? Y N P Night Sweats? Y N P HEAD Headaches? Y N P Head Injury? Y N P Migraines? Y N P Jaw/TMJ problems Y N P EYES Spots in eyes? Y N P Cataracts? Y N P Impaired vision? Y N P Glasses or contacts? Y N P Blurriness? Y N P Eye pain/strain? Y N P Color blindness? Y N P Tearing or dryness? Y N P Double Vision? Y N P Glaucoma? Y N P EARS Impaired hearing? Y N P Ringing? Y N P Earaches? Y N P Dizziness? Y N P NOSE and SINUSES Frequent colds? Y N P Nose Bleeds? Y N P Stuffiness? Y N P Hayfever? Y N P Sinus problems? Y N P Loss of smell? Y N P MOUTH and THROAT Frequent sore throat? Y N P Large amount of saliva? Y N P Teeth grinding? Y N P Sores in mouth or throat? Y N P Gum problems? Y N P Hoarseness? Y N P Dental cavities? Y N P Jaw clicks? Y N P NECK Lumps? Y N P Swollen glands? Y N P Goiter? Y N P Pain or stiffness? Y N P RESPIRATORY Cough? Y N P Sputum/phlegm? Y N P Spitting up blood? Y N P Wheezing? Y N P Asthma? Y N P Bronchitis? Y N P Pneumonia? Y N P Pleurisy? Y N P Emphysema? Y N P Difficulty breathing? Y N P Pain on breathing? Y N P Shortness of breath? Y N P Breathing worse with lying? Y N P Tuberculosis? Y N P Lung cancer? Y N P 5
6 CARDIOVASCULAR Heart disease? Y N P Angina? Y N P High/Low Blood Pressure? Y N P Murmurs? Y N P Blood clots? Y N P Fainting? Y N P Phlebitis? Y N P Palpitations/Fluttering? Y N P Rheumatic Fever? Y N P Chest pain? Y N P Swelling in ankles? Y N P GASTROINTESTINAL Trouble swallowing? Y N P Heartburn? Y N P Change in thirst? Y N P Abdominal pain? Y N P Change in appetite? Y N P Belching or passing gas? Y N P Nausea/vomiting Y N P Constipation? Y N P Ulcers? Y N P Diarrhea? Y N P Jaundice (yellow skin)? Y N P Bowel Movements: How often? Gall Bladder disease? Y N P Is this a change Y N Liver Disease? Y N P Black stools? Y N P Hemorrhoids? Y N P Blood in stool? Y N P URINARY Pain with urination? Y N P Increased frequency? Y N P Do you urinate often at night? Y N P Inability to hold urine? Y N P Frequent infections? Y N P Kidney stones? Y N P MUSCULOSKELETAL Joint pain or stiffness? Y N P Arthritis? Y N P Broken bones? Y N P Weakness? Y N P Muscle spasms or cramps? Y N P Sciatica? Y N P BLOOD/PERIPHERAL Easy bleeding or bruising? Y N P Anemia? Y N P Deep leg pain? Y N P Cold hands/feet? Y N P Varicose veins? Y N P Thrombophlebitis? Y N P MALE REPRODUCTIVE Hernias? Y N P Testicular masses? Y N P Testicular pain? Y N P Prostate disease? Y N P Discharge or sores? Y N P Impotence? Y N P Sexually transmitted disease? Y N P Premature ejaculation? Y N P - If yes, please explain Are you sexually active? Y N P _ Sexual orientation 6
7 FEMALE REPRODUCTION Age of first menses? Date of last annual exam/ PAP Age of last menses? (if menopausal) Are cycles regular? Y N Length of cycle in days? Abnormal bleeding? Y N P Duration of menses in days? Pain during intercourse? Y N P Painful menses? Y N P Clotting issues? Y N P Heavy or excessive flow? Y N P Discharge? Y N P PMS? Y N P Birth control? Y N P If yes, what are your symptoms? What type? Number of pregnancies: Breast pain/tenderness? Y N P Number of live births: Nipple discharge? Y N P Number of miscarriages or abortions: Endometriosis? Y N P Menopausal symptoms? Y N P Ovarian cysts? Y N P Abnormal PAP? Y N P Difficulty conceiving? Y N P Sexual difficulties? Y N P Cervical dysplasia? Y N P Do you do self breast exams? Y N P Are you sexually active? Y N Breast lumps? Y N P Sexual orientation: CONSENT TO TREATMENT The naturopathic doctors at RNM want to let you know that even though they are naturopathic medical doctors who have been to medical school and in some cases completed a residency in primary care, the state of Virginia does not currently recognize or license NDs. Thus Drs. Corwin and Hollon will not be able to diagnose or treat a given diagnosis of disease/illness but instead their roles will be supportive where they will serve as a consultant to improve your current health. They will be happy to work with your other physicians or health care providers. Their goal is to work as a collaborative team. Therefore, if you need additional assistance or medical care, you will be referred to others within the community that are trusted and will take good care of you. New patient visits are 1 hour and 30 minutes in duration and return visits are 60 minutes. If you are unable to make an appointment you will need to provide at least a 24- hour notice. This allows us to meet the needs of other patients that need an appointment. Due to this, appointments that are cancelled without providing a 24- hour notice will be charged a $50 cancellation fee. Payment for care is expected at the time of visit. Various forms of payment are accepted through credit card, cash or check. I understand that Drs. Corwin and Hollon are not recognized as a physician in the state of Virginia and thus their roles will be supportive, adjunctive and consultative in nature to assist in my health and well- being. I give them permission to assist in my care. I agree to indemnify and hold harmless RNM and Drs. Corwin and Hollon, its officers, directors or employees from any and all damages and/or liability arising out of or in related to naturopathic services. I also understand that all appointments cancelled without 24- hour notice will be charge a $50 fee. Signature of individual or guardian Date RNM Representative Date 7
(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
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