PATIENT INFORMATION



NATURAL MEDICAL CARE

Dr. Mehdi L. Khosh, ND Dr. Farhang R. Khosh, ND

Dr. Deena Beneda, ND Dr. Mehdi L. Khosh, ND

11030 Oakmont Street, Dr. Deena Beneda, ND

Suite 300 4935 Research Park Way

Overland Park, KS 66210 Lawrence, KS 66047

(913) 730-7600 (785) 749-2255

I. Patient Information

Patient Name (Last, First, Middle Initial) __________________________________________________________________

Parent or Legal Guardian (if a minor) ____________________________________________________________________

Address ___________________________________________________________________________________________

Birth date ____________________________________ Patient SS # __________________________________________

Sex: M or F Single__ Married __ Widowed __ Separated __ Divorced __

Home Phone __________________________ Work Phone ___________________ Ext. ____ Mobile _______________

When is the best time to reach you? _________________________ Email Address _______________________________

Occupation __________________________________ Employer/School ________________________________________

Employer/School Address ______________________________________________________________________________

Email Address _________________________________________

Whom may we thank for referring you? ___________________________________________________________________

II. Spousal Information

Spouse Name _______________________________________________________________________________________

Spouse Birth date ___________________________ Spouse SS # _____________________________________________

Spouse Occupation ____________________________ Spouse Employer ______________________________________

III. In Case of Emergency

Name _______________________________________________ Relationship ___________________________________

Home Phone __________________________ Work Phone _______________________ Mobile ____________________

IV. Responsible Party

Who is responsible for this account (if other than patient)? ____________________________________________________

Relationship to Patient ____________________ Responsible Party SS# ________________________________________

Responsible Party Home Phone ___________________________ Work Phone _____________________ Ext ________

I understand that I am financially responsible for all charges

___________________________________________________________________________________________________

Responsible Party Signature/Date

V. Family History

|Relation |Age |State of Health |Age at Death |Cause of Death |

|Father | | | | |

|Mother | | | | |

|Brothers | | | | |

| | | | | |

| | | | | |

|Sisters | | | | |

| | | | | |

Check if your blood relatives had any of the following:

|Check |Disease |Relationship |Check |Disease |Relationship |

| |Arthritis, Gout | | |Asthma, Hay Fever | |

| |Cancer | | |Chemical Dependency | |

| |Diabetes | | |Heart Disease, Strokes | |

| |High Blood Pressure | | |Kidney Disease | |

| |Tuberculosis | | |Other | |

VI. Medical History

What is the reason for your visit today? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Check the symptoms you currently have or have had in the past year:

GENERAL GASTRONINTESTINAL EYE, EAR, NOSE, THROAT MEN ONLY

__ Chills __ Appetite poor __ Bleeding gums __ Erection difficulties

__ Depression/Nervousness __ Bloating __ Blurred vision __ Lump in testicles

__ Dizziness/Fainting __ Bowel changes __ Crossed eyes __ Penis discharge

__ Fever __ Constipation __ Difficulty swallowing __ Sore on penis

__ Forgetfulness __ Diarrhea __ Double vision __ Other

__ Headache __ Excessive thirst __ Earache/Ear discharge

__ Loss of sleep __ Gas __ Hay fever WOMEN ONLY

__ Loss of Weight __ Hemorrhoids __ Hoarseness __ Abnormal Pap Smear

__ Numbness __ Indigestion __ Loss of Hearing __ Bleeding between

__ Sweats __ Nausea __ Nosebleeds periods

__ Rectal bleeding __ Persistent cough __ Breast Lump

MUSCLE/JOINT/BONE __ Stomach pain __ Ringing in ears __ Extreme menstrual

Pain, weakness, numbness in: __ Vomiting __ Sinus problems pain

__ Arms __ Hips __ Vomiting blood __ Vision - flashes/halos __ Hot flashes

__ Back __ Legs __ Nipple discharge

__ Feet __ Neck __ Painful Intercourse

__ Hands __ Shoulders CARDIOVASCULAR SKIN __ Vaginal discharge

__ Chest Pain __ Bruise easily __ Other

GENITO-URINARY __ High/Low Blood Pressure __ Hives Date of last period ______

__ Blood in Urine __ Irregular/Rapid heart beat __ Itching/Rash Date of last Pap ________

__ Frequent urination __ Poor circulation __ Change in moles Have you had a

__ Lack of bladder control __ Swelling of ankles __ Scar mammogram? _______

__ Painful urination __ Varicose veins __ Sore that won't heal Are you pregnant? ______

Number of children _____

Check (√) conditions you currently have and mark (X) conditions you have had in the past

__ AIDS __ Chicken Pox __ HIV Positive __ Polio

__ Appendicitis __ Diabetes __ Kidney Disease __ Prostate Problem

__ Arthritis __ Emphysema __ Liver Disease __ Rheumatic Fever

__ Asthma __ Epilepsy __ Measles __ Scarlet Fever

__ Bleeding Disorders __ Glaucoma __ Migraine Headaches __ Stroke

__ Breast Lump __ Heart Disease __ Multiple Sclerosis __ Thyroid Problems

__ Cancer __ Hepatitis __ Mumps __ Tuberculosis

__ Cataracts __ Herpes __ Pacemaker __ Ulcers

__ Chemical Dependency __ High Cholesterol __ Pneumonia __ Venereal Disease

VII. Medication and Allergies

List medications you are currently taking: ______________________________________________________________________________________________________________________________________________________________________________________________________________________

Pharmacy Name ___________________________________ Pharmacy Number _________________________________________

List allergies to medications or substances: ______________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII. Health Habits

Health Habits: Check which substances you Occupational: Check if your work exposes

use and describe how much you use: you to the following:

__ Caffeine __________________ __ Stress

__ Drugs ____________________ __ Heavy Lifting

__ Tobacco __________________ __ Hazardous Substances

__ Other ____________________ __ Other ______________

IX. Signatures

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Signature ___________________________________________________________________ Date ________________________

Reviewed By ________________________________________________________________ Date ________________________

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