Dear Patient, - Boise Natural Health Clinic



4219 W. Emerald St, Boise, ID 83706 | 208-338-0405 | fax 208-422-9957 | New Patient ChecklistIntake Form - Print and fill out form or create a PDF and fill out electronically.In-person appointment – Bring your intake form and other documents with you. Please wear a mask and see our web page for COVID-19 information.Video or phone appointment - The doctors need to have your completed intake form24-hours before your first visit. Ways you can send the intake form back to us:Secure Patient Portal (preferred). You will receive an email link to join when you schedule, then you can upload the document. Mail to BNHC, 4219 W. Emerald, Boise, ID 83706Drop off at the clinic during working hours.Fax (208) 422-9957Unsecure email boisenaturalhealth@Laboratory ReportsPlease provide recent (last year) laboratory reports, if available. To request records to be transferred to BNHC from other providers, you can find a Release of Records form on our web page.Supplements and MedicationsYou will save time in your appointment if you clearly list on the intake form or a separate sheet the exact names of your current medications and supplements, including the doses and brands. Clinic PoliciesPayment is due at time of service: Some insurance companies do cover some of our services, but many companies do not. We do not contract with any insurance companies and do not bill insurance on your behalf. We provide you with “insurance ready” forms for reimbursement. Please check with your insurance provider to see if our services are covered under your plan. Often Flexible Spending Accounts or Health Savings Accounts can be used for pre-tax dollar savings. Cancellation Policy: You may cancel or reschedule at no charge if you call at least 24 hours (1 business day) before your appointment. If notice is given less than twenty-four hours, you will be billed half price of the visit. If you do not cancel or fail to come for your appointment, you will be billed the full price of the visit.Fragrance Free: When you visit our office, please do not wear scents that are perceptible by others such as: perfume or scented hand lotion. We appreciate your respect to our chemically sensitive patients and staff.4219 W. Emerald Street, Boise, ID 83706 office 208-338-0405 fax 208-422-9957 ADULT PATIENT INTAKE FORMPlease take the time to carefully and thoroughly complete this health history questionnaire. Print all information and mark anything you don’t understand with a question mark. Today’s DatePERSONAL INFORMATIONFull Name I like to be called (First Middle Initial Last)Age Date of Birth Gender AddressCity State ZipPhone (best)(alternate)May we leave messages?Email Occupation Hours per week Employer & Work Address Education Military Service?Are you:Married SeparatedDivorcedSingleCohabitatingWidowedLive with:SpouseParentsAloneChildrenPartnerFriendsChildren’s AgesEmergency Contact (name and relation)Contact’s Phone How did you hear about our clinic?MEDICAL HISTORYWhat are your most important health challenges? List as many as you can in order of importance.Have you consulted any other physician or health practitioner? When and for what? What is your blood type (A/B/O)Do you have any body parts that are not your own? (Implants, transplants)?WeightWeight 1 year ago Maximum WeightWhen? ___________What childhood illnesses have you had? Please list approximate year or age:Did you have standard childhood immunizations?Immunizations for travel outside the US? Which ones and when?Any negative reactions? Explain: Approximately how many times in your life have you had antibiotics?What hospitalizations or surgeries have you had? Please list dates:FAMILY HISTORYDo your close relatives (parents, siblings, children) have any of the following medical conditions?Please circle:High Blood Pressure, Heart Attack, Stroke, Obesity, Diabetes, Glaucoma, Asthma, Hay Fever, Eczema, Skin Disease, Food Allergies, Emphysema, TB, Lung Cancer, Breast Cancer, other Cancer, Birth Defects, Suicide, Depression, Mental Illness, Alcoholism, Epilepsy, Ulcers, Arthritis, Gout, Thyroid Disease, Easy Bleeding, Sickle Cell Anemia, Osteoporosis, Other _____________________REVIEW OF SYMPTOMSPlease mark 1 (mild), 2 (moderate), or 3 (severe) if any of the following apply to you Now or in the Past.NowPastNowPastGeneralswollen or painful lymph nodesexcessive hair growthwounds heal slowlybruise easilydifficulty stopping bleedingcan’t stand heatanemiacan’t stand coldbleeding from unusual placescold hands or feetunexplained fevernight sweatsweaknessincreased thirstfatigueincreased hungerunexplained weight loss/gainexcess sweatingPlease mark 1 (mild), 2 (moderate), or 3 (severe) if any of the following apply to you Now or in the Past.NowPastNowPastSkin andpimpleshivesNailscolor changes in nailsloss of hairinfectionsskin rough, dry, scaly, bumpy, itchy (circles which applies)rashes, warts, moles, cysts (circles which applies)light or dark patches of skin (circles which applies)increased hair growth in unusual placesHeaddizzinessdouble visionheadachesfainting spellsseizures or fitsinjuriesEyescorrective lensespain, irritationinfectionsdischargeinjuries______last examEarsdischargeinfectionspain in earsinjurieshearing troubleringing or roar in earitchingstopped up earsmotion sickness______otherNosenosebleedsinjurysinus problemsloss of smelldischarge/crustspolypssneezing attacksulcersdifficulty breathing through nose______otherMouthsorespoor dentitionspeech difficultiesinfectionsloss of teethdrynessgrinding teethbad breathsore jawbad tastegum problemsroot canalsamalgam fillings______otherThroatloss of voicepaininfectionsswelling/constrictionpersistent hoarsenessdifficulty swallowingNeckstiffnessinjuriesswollen glands, enlarged thyroidRespiratoryshortness of breathwheezing/asthmacoughing spellsinfectionsexpectoration (mucus, blood)chest pain with breathPlease mark 1 (mild), 2 (moderate), or 3 (severe) if any of the following apply to you Now or in the Past.NowPastNowPastCardiovascularchest painleg vein troubleshortness of breathmurmurirregular beatankle or foot swellingfeel heart pounding/racingleg pain walkingGastrointestinalnauseavomitingblood in stooldiarrheaconstipationhemorrhoidshard, dry stoolsvomiting bloodulcerbloatinganal itchingindigestionheavy, full feeling after eatingheartburnexcess belchingparasitestrouble swallowingabdominal painfoul-odored stoolsexcessive gasirritable if late for mealsleepy during daynervous shaky feelings, headaches, relieved by eatingalternating constipation and diarrheachange in bowel movementsHow often do you have bowel movements?Urinaryfrequent urinationpainful urinationnight urinationfoul odor of urinetrouble starting urinetrouble holding urineurine dark, cloudy, foamy, bloody (circle which applies)Maledischarge from penispainful erectioninfertilityinfectionprostate problemsinjurydifficulty achieving or maintaining an erectionlumps, swelling, or pain in testiclesWhat kind of contraception do you use?Do you want birth control information?Femaledischarge from vaginapainful intercoursepelvic painflushes of heatinfertilitydifficulty feeling sexually arousedno lubrication when arousednever or seldom have orgasmsmenstrual flow is excessivemenstrual flow is absentbleeding/spotting before or after periodsbreasts: lumps, swelling, soreness (circle)infection: Type/LocationWhen?premenstrual symptoms: cramping, water retention, breast tenderness, headaches, depression, irritability, others, (circle)Female con’tWhat kind of contraception do you use?First day of last menstrual period?Usual length of cycle days, Duration of menses daysHysterectomy date__________________ Do you still have your ovaries?___________Number of Pregnancies____________ Number of Births____________Date of last annual exam / PAP Please mark 1 (mild), 2 (moderate), or 3 (severe) if any of the following apply to you Now or in the Past.NowPastNowPastMusculoskeletalback painspinal curvature or scoliosismuscle cramp. Where?joint pain or stiffness. Where?swelling. Where?injury. Where?other. Describe:Neurologicalloss of balanceparalysisfaintnesslack of strengthinvoluntary movementspeech slurredloss of consciousnessconvulsions (seizures)tremor (shaking, trembling)numbness. Where?Mentalrestlessnessnervousness/anxietyexcessive worrytrouble sleepingmemory troublecrying spellstrouble concentratingdepressionnightmaresmanic episodesexcess stressfogginess/confusionfeel like killing myselfeasily angeredfeel better from exercisingirritablefeelings of worthlessnessmood swingstrouble getting along with peopledrug abusephysical or sexual abusedifficulty expressing feelingsloss of someone dear through death or separationdon’t know how to relieve stressotherHave you had any experiences (traumatic or otherwise) that did or still do affect you deeply? Explain if you wish:THERAPIES AND LIFESTYLECurrent Medications: Please list any prescription medications, nutritional supplements, herbs or homeopathic remedies you are currently taking. Please list doses if known. Bringing bottles with you to your visit is helpful.Please list any medications, natural or prescription that you have tried in the past.Other therapiesAre you allergic to any drugs?Do you useYESAMOUNTDo you useYESAMOUNT Alcohol _________________Hormones_________________Pain Relievers_________________Laxatives_________________Birth Control Pill_________________Coffee/Caffeine_________________Soda Pop_________________Fast Food_________________Cortisone_________________Tobacco_________________Electric Blanket_________________Sleeping Aids_________________Thyroid Medication_________________Appetite Suppressants_________________Antacids_________________Sugar_________________Recreational Drugs _________________How much sleep do you get a night? Is it enough? Do you wake during the night?Do you wake refreshed in the morning? Are you exposed to chemicals? Explain:Are you under stress? Explain:Do you exercise? How often? What type?NUTRITIONHow much water do you drink a day? Do you use a water filter? Generally, what does your diet consist of?What times or how frequently do you eat? Who prepares your food? Do you snack? On what?What food(s), condiments(s), or any other substances (e.g. tobacco, alcohol, coffee, etc.) do you crave?Are you repelled by, or do you dislike any foods? Please identify:Are there any foods that do not agree with you or aggravate you? Explain:FINAL NOTESWhat do you think causes or has contributed to your health problems?What do you feel needs to happen for you to get better?What do you enjoy most in your life?What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and in adhering to the therapeutic protocols which we will be sharing with you?How much change are you willing to make at this time for improving your health? (circle)MINIMALSOME COMPLETEIs there anything else you wish to add?422338584836090%0090%3823335119126060%0060%3909060170561080%0080%4280535201993550%0050%4852035204851080%0080%5242560164846040%0040%52520851191260100%00100%493776087693570%0070%4251960153416000471043015341600047104301534160004509135153416000436626013055600043662601048385004709160114109500470916011766550024803102734310Significant Other/Romance00Significant Other/Romance32232602019935Health00Health3308985890905Money00Money2594610196850Career00Career4309110117665500433768511626850041662351534160004709160991235004480560534035Example:00Example:4160520991235004366260119126000448056013055600042519601076960004594860141986000119443564833500119443564833500208026027686000822960153416000822960276860009372603911600010515605054600011658606197600012801607340600013944608483600015087609626600016230601076960001737360119126000185166013055600093726048260PhysicalEnvironment00PhysicalEnvironment11753852734310Fun &Recreation00Fun &Recreation4514851991360PersonalGrowth00PersonalGrowth394335784225Family &Friends00Family &Friends-1771653477260WHEEL OF BALANCEWellness 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.Do the same for each area, starting from the center point radiating outwards.Thank you for taking the time to complete this form.We look forward to providing you the best possible care.00WHEEL OF BALANCEWellness 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.Do the same for each area, starting from the center point radiating outwards.Thank you for taking the time to complete this form.We look forward to providing you the best possible care. ................
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