Please fill out the following questionnaire. These questions are formulated to help your physician to understand about your health and be able to provide the proper treatment. Be advised that this information is confidential and will not be released without your Permission. PLEASE PRINT
Last name_______________________ First name_______________ Middle Initial_______________
Address______________________ City____________ State______ ZIPCode____________________
Occupation_________________________________ SSN __________________________________
Date of birth___/____/______ SEX M F Height________ Weight _____ Single__ Married_______
Home Phone (______)_______-_____________ Business Phone (______)______-_______________
Name of the Spouse/partner__________________ Closet Relative or emergency contact________________ Phone (____)_____________ Relationship _________________
IF YOU ARE FILLING OUT HIS FORM FOR A PATIENT, WHAT IS YOUR RELATIOSHIP TO PATIENT? ________________________Name___________________
Phone #_______________________
Referred by __________________________________________________________________________
What is the major complaint you are seeking help for? List in order of importance
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
4. _________________________________________________________________________________
Has there been any change in your health within the past year? _________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Last physical examination was on ________________________________________________________
Are you now under the care of a physician/chiropractor/ naturopath/osteopath/etc? Y/N
And what for _________________________________________________________________________
The name and address of physician _______________________________________________________
_________________________________________ Phone# (_______)_______- __________________
Have you had any serious illness, oppression, or been hospitalized in the past?
Name of condition Date Reason for procedure Results
1 _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
4. _________________________________________________________________________________
5. _________________________________________________________________________________
Are you taking any medicine(s) including non-prescription medicine/Vitamins/herbs/supplements? Y/N
Name Dose (mg/ml) Since how long Reason who prescribed
1._____________ ___________ _____________ ______________ _____________
2. _____________ ___________ _____________ ______________ _____________
3. _____________ ___________ _____________ ______________ _____________
4. _____________ ___________ _____________ ______________ _____________
5. _____________ ___________ _____________ ______________ _____________
6. _____________ ___________ _____________ ______________ _____________
Do you have or had the following conditions?
1. Damaged heart valves or artificial heart valves Y/N_________________________
2.Murmur or rheumatic heart disease Y/N_________________________
3. Cardiovascular disease (heart trouble, angina,
Coronary insufficiency, coronary occlusion,
High blood pressure (_________mm/hg),
Arteriosclerosis, stroke),
4. Low Pressure (_____________mm/Hg Y/N_________________________
Women
Menses
First day of Menarche____________
Are you pregnant? Y/N________________________
5. Do you have any problems associated with your menstrual period? Y/N_______________________
How many days is your cycle? __________________________________________________
6. Are you nursing? Y/N________________________
7. Did you ever nursed? Y/N________________________
8. How many pregnancies did you have? Natural/ C section Y/N________________________
9. Are you taking birth control pills? If yes, how long _______________________________________
10. What other methods do you use for protection including your husband/partner?
__________________________________________________________________________________
___________________________________________________________________________________
12.Were there any miscarriages or abortions? If yes, were they natural or induced by what ___________________________________________________________________________________
13. Is there any family member who has similar condition as yours? If so, what is it? ___________________________________________________________________________________
14. Is there any family member who has different condition than your? If so, what is it? ___________________________________________________________________________________
15. Last mammogram was______________________________________________________________
16. Last Pap exam ____________________________________________________________________
Male
Last prostate exam was _______________________________________________________________
Normal___________ Abnormal_______________
FAMILY History
# Of family members/ children Name ages
1.
2.
3.
4.
Any medical problem any of the family member has? List
1.
2.
3.
Personal History:
How committed are you to change your health? ____________________________________________________________________________________
Are you allergic to any food, drugs, pollen grass, seasonal allergy etc? Describe the reaction to ____________________________________________________________________________________
Any hobbies do you have and how often do you do?
1.
2.
3.
4.
Is there any condition, disease or problem that is not listed above that you think I should know, please explain? ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquires set forth above have been answered to the best of my knowledge. I will not hold my doctor or any other member of the staff, responsible for any errors or omissions that I have made in the completion of this form. I understand that I am responsible for all the costs of the Naturopathic medical treatments and medicine/supplements and agree that I am personally responsible for all costs. I hereby authorize the Naturopathic Medical Office to administer such as medications/supplements and perform such diagnostic and therapeutic procedures as may be necessary for my medical care.
X_____________________________________ Date__________________________
Signature of the Patient