ADULT INTAKE. Name: Date: Address: City: Prov: PC: Telephone (home): (work): Age: Date of Birth: Gender: Female / Male
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1 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: Parents: Children: Friends: Alone: Occupation: Hours per week: Is this your first visit to a Naturopathic Doctor? Yes No Are you under the care of any specialists? Yes No (Name) (Specialty) (City) How did you hear about this clinic? Has any other family member already been a patient at this clinic? Emergency contact: Relationship: Day Phone: Eve Phone CONTEXT OF CARE REVIEW Successful health care and preventive medicine are only possible when the physician has a complete understanding of the patient physically, mentally, and emotionally. The nature of your response to the following questions will go a long way in assisting my understanding of your health goals. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to assist your health needs. Why did you choose to come to this clinic?
2 CONTEXT OF CARE REVIEW CONTINUED What do you know about our approach? What three expectations do you have from this visit to our clinic? What long term expectations do you have from working with our clinic? What expectations do you have of me personally as your health care provider? What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? Rate from 0 to 10, 10 being 100% committed. 0% % What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive? What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and adhering to the therapeutic protocols which we will be sharing with you? Who do you know that will sincerely and consistently support you with the beneficial lifestyle changes you will be making? What do you love to do?
3 Wheel of Balance Wellness is a balance of many factors. Using the circle, shade your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, shade the entire pie shape for career. Family & Friends Physical Environment Career Money Do the same for each area, starting from the center point radiating outwards. Personal Growth Health What are your most important health problems? List as many as you can in order of importance. Fun & Recreation Significant Other/ Romance 1) 2) 3) 4) 5) 6) 7) 8) 9) 10)
4 FAMILY HISTORY Do you or anyone in your family have a history of any of the following? (please circle and say who) Cancer Diabetes Heart Disease High Blood Pressure Kidney disease Epilepsy Arthritis Glaucoma Tuberculosis Stroke Anemia Mental Illness Asthma Hay fever Hives Any other relevant family history? What is your family heritage? CHILDHOOD ILLNESSES Please circle whether you had any of the following as a child: Rheumatic fever Diptheria Scarlet fever Chicken pox German Measles Measles Mumps HOSPITALIZATIONS/SURGERY/IMAGING What hospitalizations, surgeries, x-rays, CAT scans, EEG, EKGs have you had? year year year year year year ALLERGIES Are you hypersensitive or allergic to: Any drugs? Any foods? Any environmentals or chemicals? CURRENT MEDICATIONS Do you take or use any of the following (please circle): Laxatives Pain relievers Antacids Cortisone Antibiotics Tranquilizers Sleeping Pills Thyroid Medication Birth Control Pills Hormone Replacement Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking: GENERAL Height: Weight: Weight one year ago: Maximum Weight: When: When during the day is your energy the best? Worst? Main interests and hobbies: Exercise: Y / N If so, what kind and how often: Watch TV: Y / N If so, how many hours? Read: Y / N If so, how many hours?
5 TYPICAL FOOD INTAKE Breakfast: Lunch: Dinner: Snacks: How many cups or glasses do you drink on average per day of the following: Coffee Black Tea Herbal tea Water Milk 2% Skim Milk Fruit Juice Soft Drinks (diet) Soft Drinks (reg) Vegetable Juice Beer Wine Liquor What is the source of your drinking water? Tap (city) Well Bottled (spring) Filtered Distilled FOR THE FOLLOWING, PLEASE CIRCLE: Y = a condition you have now N = never had P = a significant problem in the past GENERAL Do you sleep well? Y N P Average 6-8 hours? Y N P Awake rested? Y N P Have a supportive relationship? Y N P Have a history of abuse? Y N P Experienced a major trauma? Y N P Use recreational drugs? Y N P Treated for drug dependence? Y N P Use alcoholic beverages? Y N P Use tobacco? Y N P Age start? Age stop? Do you enjoy your work? Y N P Take vacations? Y N Spend time outside? Y N P Eat three meals a day? Y N P Do you go on diets often? Y N P Do you eat out often? Y N P Do you drink coffee? Y N P Drink black/green tea? Y N P Drink soda/pop? Y N P Do you eat refined sugar? Y N P Do you add salt to your food? Y N P SKIN Rashes? Y N P Eczema? Y N P Psoriasis? Y N P Hives? Y N P Acne/boils? Y N P Change in skin color? Y N P Lumps or bumps on skin? Y N P Itching? Y N P Dryness? Y N P Hair loss? Y N P Night sweats? Y N P EYES Impaired vision? Y N P Cataracts? Y N P Glaucoma? Y N P Spots in vision? Y N P Color blindness? Y N P Tearing or dryness? Y N P Eye pain or strain? Y N P Double vision? Y N P Redness? Y N P Light sensitive? Y N P Discharge? Y N P EARS Impaired hearing? Y N P Ringing in ears? Y N P Dizziness? Y N P Infection? Y N P Ear aches? Y N P Excess wax? Y N P HEAD AND NECK Headaches? Y N P Migraines? Y N P Head injury? Y N P Jaw or TMJ problems? Y N P Lumps in neck? Y N P Goiter? Y N P Pain or stiffness in neck? Y N P NOSE AND SINUS Frequent colds? Y N P Stuffiness? Y N P Sinus problems? Y N P Nose bleeds? Y N P Allergies? Y N P Loss of smell? Y N P Gum problems? Y N P MOUTH AND THROAT Frequent sore throat? Y N P Copious saliva? Y N P Sore tongue or lips? Y N P Hoarseness? Y N P Jaw clicks? Y N P Teeth grinding? Y N P Dental cavities? Y N P Gum problems? Y N P Sores? Y N P Loss of taste? Y N P RESPIRATORY Cough? Y N P Sputum? Y N P Asthma? Y N P Wheezing? Y N P Bronchitis? Y N P Coughing up blood? Y N P Pneumonia? Y N P Pleurisy? Y N P Difficulty breathing? Y N P Shortness of breath? Y N P Shortness of breath when lying? Y N P Pain on breathing? Y N P Emphysema? Y N P Tuberculosis? Y N P CARDIOVASCULAR Heart disease? Y N P Angina? Y N P High/Low blood pressure? Y N P Heart murmurs? Y N P Blood clots? Y N P
6 Fainting? Y N P Phlebitis? Y N P Palpitations/fluttering heart? 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 Change in thirst? Y N P Change in appetite? Y N P Nausea/vomiting? Y N P Ulcer? Y N P Jaundice? Y N P Gall bladder disease? Y N P Liver disease? Y N P Hemorrhoids? Y N P Pancreatitis? Y N P Heartburn? Y N P Abdominal pain or cramps? Y N P Belching or passing gas? Y N P Constipation? Y N P Bowel movements: how often? Is this a change? Y N Black stools? Y N P Blood in stools? Y N P URINARY Increased freq. of urination? Y N P Inability to hold urine? Y N P Pain on urination? Y N P Frequency at night? Y N P Frequent urinary infections? Y N P Kidney stones? Y N P Reduced flow? 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 Back pain? Y N P BLOOD Anemia? Y N P Easy bleeding or bruising? Y N P Cold hands/feet? Y N P Deep leg pain? Y N P Thrombophlebitis? Y N P Varicose veins? Y N P ENDOCRINE Hypothyroid? Y N P Hyperthyroid? Y N P Hypoglycemia? Y N P Excessive thirst? Y N P Fatigue? Y N P Heat or cold intolerance? Y N P Diabetes? Y N P Excessive hunger? Y N P Seasonal depression? Y N P Difficulty exercising? Y N P IMMUNE Reactions to immunizations? Y N P Chronically swollen glands? Y N P Slow wound healing? Y N P Chronic fatigue syndrome? Y N P Chronic infections? Y N P NEUROLOGIC Seizures? Y N P Muscle weakness? Y N P Loss of memory? Y N P Vertigo or dizziness? Y N P Paralysis? Y N P Numbness or tingling? Y N P Easily stressed? Y N P Loss of balance? Y N P MENTAL/EMOTIONAL Treated for emotional prob? Y N P Depression? Y N P Anxiety or nervousness? Y N P Poor concentration? Y N P Do you have mood swings? Y N P Tension? Y N P Memory problems? Y N P Phobias? Y N P FEMALE REPRODUCTIVE Age of first menses: Age of last menses if menopausal: Length of cycle: days Duration of flow: days Are your cycles regular? Y N P Painful menses? Y N P Heavy or excessive flow? Y N P PMS? Y N P PMS Symptoms: Depression Y N P Irritability Y N P Bloating Y N P Increased appetite Y N P Weight gain Y N P Breast tenderness Y N P Other Bleeding between cycles? Y N P Clotting? Y N P Endometriosis? Y N P Ovarian cysts? Y N P Vaginal odor? Y N P Vaginal discharge? Y N P Date of last pap smear: Abnormal PAP? Y N P Cervical dysplasia? Y N P Are you sexually active? Y N P Birth control? Type: Pain during intercourse? Y N P Herpes? Y N P Chlamydia? Y N P Genital warts? Y N P Syphilis? Y N P Difficulty conceiving? Y N P Number of pregnancies: Number of live births: Number of miscarriages: Number of abortions: Do you do self breast exams? Y N P Breast pain/tenderness? Y N P Breast lumps? Y N P Nipple discharge? Y N P Menopausal symptoms? Y N P MALE REPRODUCTIVE Are you sexually active? Y N P Discharge or sores? Y N P Chlamydia? Y N P Genital warts? Y N P Gonorrhea? Y N P Herpes? Y N P Syphilis? Y N P Hernias? Y N P Testicular masses? Y N P Testicular pain? Y N P Prostate disease? Y N P Impotence? Y N P Premature ejaculation? Y N P Number of children: Thank you for your time and effort. We look forward to providing you with the best possible care. If there is anything else you would like to add at this time please do so on the back of this page.
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