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PATIENT PROFILE

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PATIENT PROFILE Powered By Docstoc
					                     Naturopathic Medical Adult Intake Form
                           The Core Centre of Health
                    #102 – 1441 Ellis Street Kelowna, BC V1Y 2A3 | P: 250-862-2673
                                       www.thecorekelowna.com
                                   PATIENT MEDICAL PROFILE
Last Name:__________________________First Name: ______________________ Today’s Date:________

Nickname:__________________ E-Mail:____________________ Birth Date:___________ Sex:__________
Home Address:_______________________________ City:____________ Postal Code: ________________
Home Phone:_______________             Work Phone:___________________ Cell Phone: ___________________
Preferred Method of communication: Home           Cell       Work    or email
How did you hear about Naturopathic Medicine at The Core Centre of Health? ________________________
A note to our patients: Please complete this two-sided questionnaire as thoroughly as possible in order to
best aid in your diagnosis and treatment. This is a confidential record of your medical treatment and will not
be released, except when you have provided us with written authorization to do so. Thank you.

                                       PRESENT HEALTH CONCERNS

 Please list most important health concerns in   Is there a prior diagnosis of this problem? If so, what was diagnosis,
 their order of significance.                    when was it made and by whom?

 1.

 2.

 3.

 4.

 5.


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:______________________________________________________
Explain:__________________________________________________________________________________________________


                                                         1
Name ______________________________________________            DOB: _______________________________

Current Symptoms
General                         Respiratory                        Genitourinary (con’t.)         Neurological (con’t.)
   o      Chills                Cough                              Nighttime urination            Seizures
   o      Fatigue               Difficulty breathing               Painful intercourse            Tremor
   o      Fever                 Coughing up blood                  Painful menstruation           Vertigo (Dizziness)
   o      Night Sweats          Chest wall pain                    Painful urination              Weakness
   o      Weight Change         Wheezing                           Sexual abuse                   Hematologic
Eyes                            Gastrointestinal                   Unprotected sex                      o Easy bruising
   o      Blurred Vision        Abdominal pain                     Urinary incontinence                 o Excessive bleeding
   o      Eye Drainage          Indigestion                        Vaginal discharge                    o Blood transfusions
   o      Eye Pain              Sour taste in mouth                Vaginal itching                      o Enlarging lymph
                                                                                                        nodes
   o      Glasses/contacts      Poor appetite                      Musculoskeletal
                                                                                                   Endocrine
   o      Light Sensitivity     Bloating                           Arm or leg pain
                                                                                                  Enlarging hands/feet
Ears/Nose/Throat                Difficulty swallowing              Back pain
                                                                                                  Hair loss
   o      Ear pain              Clay-colored stools                Joint pain
                                                                                                  Heat intolerance
   o      Hearing problems      Constipation                       Joint stiffness
                                                                                                  Cold intolerance
   o      Ringing in ears       Diarrhea                           Muscle aches
                                                                                                  New hair growth
   o      Nose bleeds           Heartburn                          Skin
                                                                                                  Hot flashes
   o      Nasal congestion      Vomiting blood                     Acne
                                                                                                  Darkening skin
   o      Nasal ulcers          Bloody stools                      Concerning moles
                                                                                                  Infertility
   o      Runny nose            Hemorrhoids                        Dry skin
                                                                                                  Increased thirst
   o      Bleeding gums         Dark/tarry stools                  Fingernail problems
                                                                                                  Increased hunger
   o      Gum disease           Nausea                             Jaundice (Yellow skin)
                                                                                                  Stretch marks
   o      Dentures present      Vomiting                           Itching
                                                                                                  Sweating excessive
   o      Hoarseness            Painful chewing                    Rashes
                                                                                                   Allergies/Immunologic
   o      Oral ulcers           Stool caliber change               Warts
                                                                                                  Allergies
   o      Sore throat           Genitourinary                      Breast
                                                                                                  Hay fever
   o      Sore tongue           Bleeding after intercourse          o Lump
                                                                                                  Frequent colds
   o      Thrush                Blood in urine                      o Skin changes
                                                                                                  HIV exposure
   o      Tooth pain            Change in urine stream              o Breast tenderness
                                                                                                  Urticaria (Hives)
Cardiovascular                  Frequent bacterial vaginosis        o Nipple discharge
                                                                                                   Psychiatric
   o      Chest pain            Frequent Bladder infections         o Regular self-breast exams
                                                                                                  Anxiety
   o      Leg pain w/ walking   Frequent urination                 Neurological
                                                                                                  Depression
   o      Dizziness             Genital lesions                    Difficulty walking
                                                                                                  Stress
   o      Shortness of breath   Heavy periods                      Dizziness (fainting)
                                                                                                  Mood Disorders
   o      Palpitations          Impotence                          Fainting
                                                                                                  PMS
   o      Swollen feet/ankles   Irregular periods                  Headaches
                                                                                                  Poor concentration
   o      Rapid heart rate      Menopausal bleeding                Memory loss
                                                                                                  Trouble sleeping
   o      Varicose veins        Menopausal symptoms                Numbness
                                                                                                  Suicidal thoughts
                                                               2
Name ______________________________________________           DOB: _______________________________

Past Medical History
Cardiovascular                      o Crohn’s Disease                  o Osteopenia                     o Iron Deficiency Anemia
      o Abnormal Heart              o Incontinence of Feces            o Rheumatoid Arthritis           o Pervasive
      Rhythm                                                                                            Developmental Delay
                                    o GERD or Heartburn                o Systemic Lupus
      o Arterial Clot                                                  Erythematous                     o Seizures
                                    o Hepatitis
      o Carotid Artery Disease                                         o Other                          o Transient Ischemic
                                    o Irritable Bowel
                                                                                                        Attacks (TIA’s)
      o Congestive Heart            Syndrome (IBS)                Endocrine
      Failure                                                                                           o Pernicious Anemia
                                    o Pancreatitis                     o Addison’s Disease
      o Coronary Artery                                                                                 o Sickle Cell Disease
                                    o Peptic Ulcer Disease             o Carcinoid Syndrome
      Disease
                                                                                                        o Thallasemia
      o Deep Vein Thrombosis        o Ulcerative Colitis               o Cushing’s Disease
                                                                                                Allergy/Immune/Skin
      o High Cholesterol         Renal                                 o Diabetes I or II
                                                                                                        o Allergies (food or
      o Hypertension                o Benign Prostatic                 o Hyperthyroidism
                                                                                                        environmental)
                                    Hypertrophy                        o Hypothyroidism
      o Heart Attack                                                                                    o Angioedema
                                    o Chronic Renal Failure
      o Peripheral Vascular                                            o Panhypopituitarism             o Chicken Pox
      Disease                       o Endometriosis
                                                                       o Pituitary Tumor                o Eczema
      o Superficial Vein Clot       o Bed Wetting
                                                                  Neurological                          o Giardiasis
      o Phlebitis                   o Erectile Dysfunction             o Alzheimer’s Disease
                                    (Impotence)                                                         o Immune Deficiency
      o Heart Valve Disease                                            o ADD/ADHD
                                    o Glomerulonephritis                                                o Ear Infections
Pulmonary                                                              o Autism                         (frequent)
                                    o Infertility
      o Asthma                                                         o Cerebral Palsy                 o Psoriasis
                                    o Kidney Stones
      o Bronchiectasis                                                 o Stroke                         o Sinusitis
                                    o Urinary Incontinence
      o Chronic Bronchitis                                             o Dementia               Psychiatric
                                    o Frequent Bladder
      o COPD                        Infections                         o Degenerative Disc              o Anxiety
      o Croup                                                          Disease                          o Anorexia Nervosa
                                 Musculoskeletal/Connective
      o Cystic Fibrosis          tissue                                o Headaches                      o Bipolar Disorder
                                    o Chondromalacia                   o Huntington’s Disease
      o Pneumonia                                                                                       o Bulimia
                                    Patellae
      o Pulmonary Embolism                                             o Meningitis                     o Depression
                                    o Chronic Pain
                                                                       o Mental Retardation             Obsessive Compulsive
      o Pulmonary
                                    o Fibromyalgia
      Hypertension                                                     o Multiple Sclerosis             o Schizophrenia
                                    o Fractures
      o Respiratory Syncytial                                          o Muscular Dystrophy     Other
      Virus (RSV)                   o Gout
                                                                       o Myasthenia Gravis              o Cataract
      o Sarcoidosis                 o Juvenile Rheumatoid
                                                                       o Parkinson’s Disease            o Glaucoma
      o Sleep Apnea                 Arthritis
                                                                       o Sensory Neuropathy             o Over weight
                                    o Osgood-Schlatter
      o TB
                                    Disease                       Hematologic                           o __________
Gastrointestinal
                                    o Osteoarthritis                   o Hemolytic Anemia               o __________
      o Gall Stones
                                    o Osteoporosis                                                      o __________
      o Cirrhosis
      o Colon Polyps




                                                              3
Name ______________________________________________             DOB: _______________________________


Other Healthcare Providers you are currently seeing (Please list all – conventional, holistic, integrative…etc.)
Dr. _____________________________ specialty ________________________ Phone: ___________________________
Dr. _____________________________ specialty ________________________ Phone: ___________________________
Dr. _____________________________ specialty ________________________ Phone: ___________________________
Dr. _____________________________ specialty ________________________ Phone: ___________________________


Date of last physical/annual exam________________________ Date of last blood tests: ________________________________



Surgical History (please list surgeries, dates and outcomes)




Family History
Relation          Medical Condition                                                Age at Death      Cause of Death
Father
Mother
Brother(s)
Sister(s)
Son(s)
Daughter(s)
Paternal GF
Paternal GM
Maternal GF
Maternal GM




                                                                 4
Name ______________________________________________            DOB: _______________________________



Pregnancy/Gynecological History
Pregnancies    # _____              o Menstrual problems           Current Birth Control Method        Last Pap Smear (date)
                                                                   ____________                        ________
Children       # _____              o Hysterectomy                 Are you happy with current birth    Last Mammogram (date)
                                                                   control method?                     ______
Miscarriages   # _____              o Total                        Age periods started _____

Terminations # _____                o Partial (ovaries             Age at menopause _____
                                    retained)
Problems during pregnancy?
______



Social History
Occupation _______________      Caffeine                           How often do you use               Recreational Drugs
Marital Status ____________     Type and number of drinks per      Alcohol?                           Frequency __________
Hobbies _________________       day ______________________         o None
________________________        __________________________         o Rare                             Types_______________
Exercise (type and frequency)                                      o Social
________________________        Smoking                            o Regular                          How long? _________
________________________        Current? In the past? Never?       o Occasional Binge
Children? Names and ages        How long? ______________           o Current Alcoholic                Do you Restrict any Foods?
                                Type? Cigarettes? Cigar?           o Past Alcoholic                   Which? __________________
__________________________      Smokeless?                                                            _________________________
                                                                   o Used alcohol in past



What goals do you have for your visit to The Core today?




Please include any other comments or health concerns that you would like to discuss:




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