Rogue Valley Natural Medicine Holistic Health Services
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- Brendan French
- 7 years ago
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1 Welcome to our clinic! Here s a checklist to help get you ready for your first visit: _ New patient paperwork filled out. _ Bring all the supplements/medications that you are currently taking. _ Women please wear pants (no skirts) to your visits. _ Avoid wearing perfumes, essential oils, scented hair products, scented lotions. The first visit will be approx one hour and 30 minutes. Please arrive 10 minutes before your scheduled time
2 Intake Form Name: Date: Address: City: State: Zip: Telephone (home): (work/cell): address: 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: Employer: How did you hear about this Clinic? Emergency contact: Relationship: Phone: Health History Questionnaire What are your most important health problems? List in order of importance. 1) 2) 3) 4) 5) 6) Family History Do you have a family history of any of the following? (Please check) _ Cancer _ Stroke _ High Blood pressure _ Kidney Disease _ Hay Fever _ Mental Illness _ Asthma _ Heart Disease _ Glaucoma _Tuberculosis _ Arthritis _ Hypothyroidism _ Diabetes _ Anemia _ Depression/Anxiety _ Epilepsy _ Hives _ Alcoholism Hospitalizations/Surgery/Accidents What hospitalizations or surgeries have you had? List any accidents: List any broken bones and dislocations: Were you ever knocked unconscious? Y N Have you ever had a lapse of memory? Y N - 2 -
3 Patient Evaluation Questionnaire 1. Please rate on scale how serious you are about getting well (circle number) Not Serious Very Serious 2. Would you prefer: (Please Check) _ Correction of Cause of Health Problems _ Temporary Symptom Relief 3. Are you willing to follow a treatment program designed to help you return to health? (Treating the Cause) 4. Are you willing to take nutritional and/or homeopathic supplements? 5. Are you willing to make dietary changes? 6. Are you willing to start a moderate exercise program? 7. Please rate on scale how serious you are about staying healthy after your initial intensive care Not Serious Very Serious 8. Are you familiar with Applied Kinesiology? _ Very little (somewhat) If yes, how were your results? 10. Please rate your stress on scale No Stress Total Stress 11. Are any other doctors or practitioners currently treating you? If yes, please list - 3 -
4 Toxic Profession Past of Present (Artist, graphic designer, dental asst, gas station worker, painter, industry, cleaners, etc.) Major Psychological Trauma Serious Infections/Diseases (pneumonia, mono, TB, cancer, heart attack, stroke, hepatitis, etc) Long periods on prescriptions or street drugs Long visits or lived in a foreign country like India, Mexico, Africa, etc. Treated for parasites, infection? Y N Allergies Are you hypersensitive or allergic to... Any drugs? Any foods? Any environmentals? Laxatives _ Cortisone _ Tranquilizers _ Pain relievers _ Appetite suppressants Current Medications _ Thyroid medication _ Birth control pills _ Antacids _ Sleeping pills _ Antibiotics Please list any prescription medications, over-the-counter medications, vitamins or other supplements you are taking: - 4 -
5 Typical Food Intake Breakfast: Lunch: Dinner: Snacks: Drinks: Habits Main interests and hobbies Do you exercise? Y N If yes, what kind? How often? Average 7-8 hrs sleep? Y N Sleep Well? Y N Awaken rested? Y N When during the day is your energy the best? Worst? Have a supportive Relationship? Y N Have a history of Abuse? Use Recreational drugs? Do you eat three meals a day? Y N Do you eat out often? Y N Do you drink coffee? Y N Do you drink black/green/herbal teas? Y N Enjoy your work? Y N Take vacations? Y N Spend time outside? Y N Watch television? Y N How many hours per day? Alcoholic beverages? How many drinks per week? Smoke? How much per day? How many years? Do you have a religious or spiritual practice? Y N If yes, what? How does your condition affect you? What do you think is happening? Why? What do you feel needs to happen for you to get better? How long do you think it will take for you to get better? - 5 -
6 Review of symptoms Y = a condition you have now N= never had P= a condition you have had before Appendicitis Chicken Pox Polio Alcoholism Whooping cough Epilepsy Anemia HIV Measles Multiple Sclerosis Mumps General Chills Loss of Sleep Convulsions Loss of Weight Fainting Neuralgia Fatigue Sweats Fever Mental/Emotional Treated for emotional problems Depression Mood swings Anxiety or nervousness Considered/Attempted suicide Tension Poor concentration Memory problems Endocrine Hypothyroid Diabetes Hypoglycemia Excessive hunger Excessive thirst Seasonal depression Fatigue Night sweats Heat or Cold intolerance Immune Chronic fatigue Syndrome Reactions to vaccinations Chronic swollen glands Chronic infections Slow wound healing Neurologic Seizures Numbness or tingling Muscle weakness Easily stressed Loss of Memory Loss of Balance Vertigo or dizziness Fainting Paralysis - 6 -
7 Skin Rashes Lumps Eczema or Hives Itching Acne/Boils Hair loss Color change Bruises easily Head Eyes Ears Nose Throat Headaches Dizziness Migraines Frequent colds Head injury Stuffy nose Jaw/TMJ problems Runny nose Spots in eyes Sinus problems Impaired vision Nose bleeds Blurriness Hay fever Color blindness Loss of smell Double vision Frequent sore throat Cataracts Teeth grinding Glasses and/or contacts Gum problems Eye pain/strain Dental cavities Tearing or dryness Sores on tongue or lips Glaucoma Hoarseness Impaired hearing Difficulty swallowing Ear aches Goiter Ringing in the ears Swollen glands Respiratory Cough Shortness of breath Persistent cough Shortness of breath at night Spitting up blood Tuberculosis Asthma Spitting up phlegm Pneumonia Wheezing Emphysema Bronchitis Pain on breathing Cardiovascular Heart disease Varicose veins High blood pressure Murmurs Low blood pressure Blood clots Pain over heart Phlebitis Poor circulation Rheumatic fever Rapid heart Swelling in ankles Slow heart beat Palpitations/fluttering Stroke - 7 -
8 Gastrointestinal Trouble swallowing Heart burn Change of thirst Change in appetite Nausea Constipation Vomiting blood Diarrhea Blood in stool Gallbladder trouble Abdominal pain/cramps Ulcer Belching or passing gas Hemorrhoids Black stools Poor appetite Liver trouble Poor digestion Bowel movements: How often? Is this a change? Y N Urinary Pain on urination Kidney stones Frequency at night Blood in urine Frequent infections Kidney infection Increased frequency Prostate trouble Inability to hold urine Male Reproduction Hernias Premature ejaculation Testicular pain Testicular masses Venereal disease Prostate disease Impotence Discharge or sores Female Reproduction/Breasts Age of first menses Discharge Age of last menses Herpes Length of cycle days Venereal disease Duration of menses days IUD Painful menses Birth control Heavy of excessive flow What type? PMS Number of pregnancies If yes, what are your symptoms? Number of live births Number of miscarriages Endometriosis Number of abortions Ovarian cysts Hot flashes Difficulty conceiving Lump in breast Are cycles regular? Have you had a mammogram? Y N Bleeding between cycles Last Pap smear date: Pain during intercourse Was it normal? Y N Clotting Muscles/Joints/bones Backache Stiff neck Foot trouble Swollen joints Pain trouble Tremors/twitching Shoulders Arm trouble Painful tail bone - 8 -
9 If you have musculoskeletal pain, please complete the following: Please mark the intensity of your pain today: 0 = no pain to 10 = intense pain Area: Intensity: Area: Intensity: Area: Intensity: Area: Intensity: How long has this condition lasted? Is this condition: _ Getting worse _ The same _ Improving Was this caused by an injury/accident? _ Y _ N If no, when did you first notice it? Pain came on: _ Gradually _ Suddenly The pain is: _ Occasional _ Frequent _ Constant Describe the pain: _ Sharp (knife-like) _ Dull (toothache) _ Burning (hot) Does the pain: _ Stay in one spot _ Radiate (shoots) _ Goes up and down the spine What time is the pain worst: _ Morning _ Afternoon _ Evening _ Night _ All the time Do you have pain in: _ Legs _ Feet _ Arms _ Hands _ Left _ Right Numbness or tingling in: _ Legs _ Feet _ Arms _ Hands _ Left _ Right What makes the pain worse? What makes the pain better? Does the pain affect you sleeping: _ Occasionally _ Frequently _ Constantly Does the pain affect your work: _ Occasionally _ Frequently _ Constantly Have you been hospitalized in the past five years? If yes, for what? Have you had major surgery in the past five years? If yes, for what? Have you had other doctors for this condition? If yes, doctor(s) name(s) - 9 -
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