VALLEY NATUROPATHIC FAMILY MEDICINE
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DATE
Last Name: First Name:
Birth date: Sex/Gender:
Address: _____________________________________________________________________ Apt: ___
City: __________________________________ State: ________ Zip: _____________
Home Phone: ___________________Work Phone:_____________________ Cell phone
(which is best to reach you at? IS it OK to leave a message?)
Email address:
Mother and Father Name s (minors only): _______________________________________________________________________
Emergency Contact and phone number: ____________________________________________
Married Single Significant Other Do you have children? Ages:
Insurance_____________________Phone______________Group # ID#
It is your responsibility to know the extent of your insurance coverage and copays if applicable.
Present Health Concerns: For chronic, or long standing health conditions, please make a “timeline”, including important dates, medications, outcomes etc…
|Please list most important health concerns in |Prior diagnosis of this problem? If so, |Indicate painful or distressed areas: |
|their order of significance. |what? | |
| | | |
|1. | | |
| | | |
|2. | | |
| | | |
|3. | | |
| | | |
|4. | | |
| | | |
|5. | | |
Have you ever consulted a Naturopathic physician, an Acupuncturist, a Nutritionist or a Homeopath before?
Please list prescription medications that you are currently taking, with dosages:
1. 2. 3.
4. 5. 6.
List vitamins, minerals, herbs, homeopathic remedies that you are currently taking, with dosages:
1. 2. 3.
4. 5. 6.
Please list any severe or life-threatening allergies (drug, food, environmental): :
Hospitalizations:
Where did you grow up? Where have you lived in the past?
Serious Illnesses and Injuries:
Date of last physical/annual exam
Who is your Primary Care Physician? Phone and fax #
HEALTH SCREENING HISTORY: List the date of your most recent test or exam.
Mammogram ____ Pap Smear_____ Self Breast Exam ______Breast Exam by Professional _________
Self Testicle Exam _____ Testicle Exam by Professional_________ Prostate Exam by Professional ____________
Test for Blood in stool ______Rectal Exam ______Scope of Lower Bowel (if over age 50)______________
Blood tests: Cholesterol _________ Blood Sugar ________Other Blood Tests____________
Personal and Family History:
Please check the “yes” box next to each condition that applies to you or one of your family members. Please note whether condition applied to family member in the past or currently by denoting a “P” for past or “C” for current. Indicate the relationship or the word “self” in the “Relationship” column.
| |YES |RELATION |DATES RESOLVED | |YES |RELATION |DATES RESOLVED |
| | | |Past(P)/Current(C) | | | |Past(P)/Current(C) |
|Alcoholism/Drug | | | |Headaches | | | |
|Addiction | | | | | | | |
|Allergies | | | |Heart Disease | | | |
|Anemia | | | |Hepatitis | | | |
|Arthritis | | | |High Blood Pressure | | | |
|Asthma | | | |Kidney Disease | | | |
|Cancer | | | |Mental Illness | | | |
|Depression | | | |Stroke | | | |
|Diabetes | | | |Tuberculosis | | | |
|Eczema | | | |Lyme Disease | | | |
|Epilepsy | | | |Other | | | |
SLEEP: Hrs of sleep____ Fall asleep O.K?____ Sleep through night? ____Wake rested? _______
What awakens you?_________________________________________________________
WORK: Hr/wk you work ____ Do you enjoy work?___ What do you do?_____________________
Hr/day commute_____ Employer____________
EXERCISE: Regularly?____Wha type?________How long/often?__________________
DIET? ______________________ How many meals a day? ___________
Are you satisfied with your diet? _____ Cravings? _____________________________
Breakfast:_____________________________________________________________________
Lunch: _______________________________________________________________________
Dinner: _______________________________________________________________________
Snacks: ____________________________________________________
Alcohol________________Caffeine (coffee, black tea, soda) ____________ Tobacco____________
Recreational Drugs ____________
LEISURE: activities/hobbies____________________
REVIEW OF SYSTEMS (C= you have now: P= you had in past)
Height______ Weight ______ Maximum Weight ______ When?_________ Easy Weight Gain? ____
Length of time for weight gain/loss if you are over/underweight?______________
GENERAL: Night sweats____ Fatigue____ Do you tend to feel more cold/hot?________
SKIN: Rashes ____ Hives______Psoriasis_____Eczema____Warts______Infection____ Growths Hair/Nail Changes_____ Other__________
HEAD: Headaches____ Head Injury____ Other__________
EYES: Impaired vision_________Eye Pain____ Tearing/Dryness____Double Vision_____
Poor night vision____ Floaters____ Loss of vision____ Other__________
EARS,NOSE,SINUS:FrequentColds________Dizziness________Ringing_______Earache______Nse Bleeds________ Stuffiness___________
Sinus Problems_______ Post Nasal Drip_______ Other________________________________
MOUTH, THROAT: Frequent Sore Throat______ Sore Tongue_______Gum Problems_______
Dental Problems____Cavities/fillings______ Sores in mouth/on lips____ Teething Grinding______Hoarseness__________ Other_________________________________________________________________________
RESPIRATORY: Cough____ Spitting up Blood____ Wheezing____ Difficulty Breathing_______
Pain on Breathing_____ Shortness of Breath____ When?(night, lying down, etc)____________
Mucus ______ Other___________________________________________________________
HEART/CIRCULATION: Heart Disease_____ High Cholesterol____ High Blood Pressure_____ Chest Pain _____ Swelling in Ankles_____ Palpitations/Fluttering_____ Deep Leg Pain____
Cold Hands/Feet____ Varicose Veins____ Heart Murmur _____ Other__________
DIGESTION: Change in Thirst_____ Change in appetite_____ Trouble Swallowing_____ Heartburn_____ Stomach Pain_____ Nausea_____ Vomiting_____ Loose Stools_____ Gas_____ Burping____ Bloating____ How many bowel movements per day? ____ Is this a change?______ Blood in Stools____ Hemorrhoids____ Fissure____ Liver or Gall Bladder Disease ____________
Anal discomfort _____ Other________________________________________________________
URINARY: Pain on Urination______ Increased Frequency or urgency____ Frequency at Night____
Inability to Hold Urine____ Bladder Infections____ Other________________________________
NEUROLOGICAL: Fainting ____ Seizures____ Paralysis_____ Muscle Weakness____ Numbness or Tingling____ Loss of Concentration/ Memory____ Coordination problem_____ Other________
HORMONAL: Thyroid issues____ Diabetes_______Heat/Cold Intolerance____ Hypoglycemia____ Other_________
BLOOD/ LYMPH: Anemia____ Easy Bleeding or Bruising____ Swollen Glands ____ Other______
EMOTIONAL Depression____ Mood Swings____ Anxiousness or Nervousness___ Tension___ Anger/Irritability____ Indecisiveness____ Family History________Other__________
FEMALE REPRODUCTION: Age Menses Began____ Length of Complete Cycle ____
Date of Last Menstrual Period________ ndometriosis_____Excessive facial or body hair_____
Number of Days Menstrual Flow____ Bleeding Between Periods____ Excessive Flow____
Are Cycles Regular____ Cramps____ Premenstrual Symptoms:____________________________
Abnormal Vaginal Discharge or drynesss____ Date of Last Pap Smear____ Abnormal Pap Smears? ____
Number of Pregnancies____ Number of Live Births____ Number of Miscarriages____
Sexually Active (men, woman, both)____ Birth Control____(Type ________________) Pain During Intercourse_____
Sexual Difficulties____ Difficulty Conceiving____ Venereal Disease_______________________
Number of Abortions_____(Optional) Sexual Orientation: ___________________(Optional)
Menopausal Symptoms______________________________________________________________
Regular Self-Breast Exam____ Lumps____ Pain/Tenderness____ Nipple Discharge____
MALE REPRODUCTION Regular Self-Testicular Exam?____ Testicular Mass____ Testicular Pain____ Sexually Active _______Sexual Difficulties____ Prostrate Problems____ Venereal Disease____ Sores ____ Discharge____ Difficulty Urinating______
Birth Control ____ (Type ____________) Sexual Orientation____________ (Optional)
MUSCULOSKELTAL:
Joint Pain/Stiffness____ Morning stiffness____ (lasts how long?________) Broken Bones____
Hernias ____ Weakness____ Restless Leg_____Motor Vehicle Accidents_______
Indicate any problem areas on diagram below:
[pic] [pic]
(IF NOT NOTED ABOVE IT IS NEGATIVE, NON-CONTRIBUTORY, AND/OR NON-PERTINANT
I certify that the information that I have supplied is correct and accurate to the best of my knowledge.
Printed Name ______________________________________________________________ Date _____________________
Signature____________________________________________________ Relationship to Patient: _________________________
How did you hear about me? Newspaper? Mailer/Flyer Website Workshop/Event Medical Referral Friend/Family Insurance Co. Other:
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Patient name__________________________________DOB____________________
Patient name________________________________________DOB________________________
Patient name______________________DOB_______________________________
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