BEAVERTON CENTER FOR THE HEALING ARTS - Redwood Clinic

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   Redwood Clinic
               7017 NE Highway 99, suite 210 Vancouver, WA 98665 (360) 936-9875
                                              New Patient Intake Form
Name ____________________________________ Date of First Visit _______________
Address _________________________________________________________________
City ____________________________              State ______________        Zip Code ___________
Telephone # (home)_______________________ (work) _________________________
E-mail _________________________________                  S.S.# _______________________
Age ______      Date of Birth ___________________Gender: female ____male ____other ____
Occupation _______________________
How did you hear about our clinic? ___________________________________________

Next of Kin or other to reach in an emergency ___________________________________

Relationship ____________________ Phone __________________________________


                             HEALTH HISTORY QUESTIONNAIRE

SUCCESSFUL HEALTH CARE AND PREVENTIVE MEDICINE ARE ONLY POSSIBLE WHEN THE PHYSICIAN HAS A COMPLETE
UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS
THOROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON'T UNDERSTAND WITH A QUESTION MARK.

Are you currently receiving healthcare? Y N

If yes, where and from whom?_______________________________________________
________________________________________________________________________

What are your most important health problems? List as many as you can in order of
importance.
      1)
      2)
      3)
      4)
      5)
      6)
                                                                                     2

                                       Medical History:
Check those applicable YES    NO               Comments:
Cancer                 ______ ______             ________________________________
Chronic Pain           ______ ______             ________________________________
Diabetes               ______ ______             ________________________________
Heart Disease          ______ ______             ________________________________
High Blood Pressure    ______ ______             ________________________________
Blood clots            ______ ______             ________________________________
Stroke                 ______ ______             ________________________________
Epilepsy               ______ ______             ________________________________
Mental Illness         ______ ______             ________________________________
Asthma/Hayfever/Hives ______ ______              ________________________________
Anemia                 ______ ______             ________________________________
Anoxeia/unable to eat  ______ ______             ________________________________
Anxiety                ______ ______             ________________________________
Arthritis              ______ ______             ________________________________
GI/ Stomach issues     ______ ______             ________________________________
Depression             ______ ______             ________________________________
Hepatitis              ______ ______             Type: ___________________________
HIV                    ______ ______             ________________________________
Chronic Nausea         ______ ______             ________________________________
Chronic Vomiting       ______ ______             ________________________________
Seizure                ______ ______             ________________________________
Severe Headache        ______ ______            How many a month:________________
Thyroid issues         ______ ______             ________________________________
Trouble Sleeping       ______ ______             ________________________________
Trouble losing weight  ______ ______             ________________________________
Kidney Disease         ______ ______             ________________________________
Glaucoma               ______ ______             ________________________________
Tuberculosis           ______ ______             ________________________________



                               Hospitalization and Surgery

What hospitalizations or surgeries have you had?

                               year:                                    year:
                               year:                                    year:

                               year:                                    year:

                                    X-Rays and Special Studies
X-rays, MRI, CAT scans, or other studies you have had:
________________________________________________________________________
________________________________________________________________________
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                                           Allergies
Are you hypersensitive or allergic to...
Any drugs?
Any foods?
Any environmentals?

                                      Current Medications
Do you take or use?
Laxatives      Y N          Pain relievers             Y N    Antacids          Y N
Cortisone      Y N          Appetite suppressants      Y N    Antibiotics       Y N
Tranquilizers Y N           Thyroid medication         Y N    Sleeping pills    Y N

Please list any prescription medications, over the counter medications, vitamins or other
supplements you are taking?
1) _________________________________ 4) _________________________________
2) _________________________________ 5) _________________________________
3) _________________________________ 6) _________________________________


                               FEMALE REPRODUCTION
Age of first menses?
Age of last mense?                       Are cycles regular?                    Y       N
Length of cycle?                    days Bleeding between cycles?               Y   P   N
Duration of menses?                 days Pain during intercourse?               Y   P   N
Painful menses?                   Y P N  Clotting?                              Y   P   N
Heavy or excessive flow?          Y P N  Discharge?                             Y   P   N
PMS?                              Y P N  Birth control?                         Y   P   N
If yes, what are your symptoms?                What type?
                                         Number of pregnancies
                                         Number of live births
Endometriosis?                    Y P N  Number of miscarriages
Ovarian cysts?                    Y P N  Number of abortions
Difficulty conceiving?            Y P N  Menopausal symptoms?                   Y   P   N
Cervical Dysplasia?               Y P N  Abnormal PAP?                          Y   P   N
Sexual difficulties?              Y P N  Chlamydia?                             Y   P   N
Gonorrhea?                        Y P N  Condyloma?                             Y   P   N
Herpes?                           Y P N  Syphilis?                              Y   P   N
Are you sexually active?          Y   N  Sexual orientation:
Do you do breast self exams?      Y P N  Breast lumps?                          Y P N
Breast pain/tenderness?           Y P N  Nipple discharge?                      Y P N
                                                                                  4

  Please answer the following questions about your condition that you have
                   choose to be seen for today, thank you.

How long have you has your condition (s):

Condition: ________________________      Time: _________________________

Condition: ________________________      Time: _________________________

What makes your condition feel better:

_____________________________________________________________________
What makes your condition feel worse:

_____________________________________________________________________

What have you tried in the past to treat your condition:

______ Prescription medication                       ______ Heat
______ Pain killers                                  ______ Ice
______ Muscle relaxers                               ______ Pool therapy
______ Over the counter pills                        ______ Rest
______ Chiropractic                                  ______ Injections
______ Physical therapy                              ______ Surgery
______ Acupuncture                                   ______ Behavioral Health
______ Massage                                       ______ other: ____________

What are you currently using to treat your condition:

______ Prescription medication                       ______ Heat
______ Pain killers                                  ______ Ice
______ Muscle relaxers                               ______ Pool therapy
______ Over the counter pills                        ______ Rest
______ Chiropractic                                  ______ Injections
______ Physical therapy                              ______ Surgery
______ Acupuncture                                   ______ Behavioral Health
______ Massage                                       ______ other: ____________

Current height: _______ feet ______ inches           Weight: ________ pounds
                                                                         5

                For conditions involving pain only:

0= no pain                 5= moderate                 10= severe pain

Pan scale: 0 1 2 3 4 5 6 7 8 9 10


                     Please circle the area of pain:




             FRONT                              BACK
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                           YOUR HEALTH INFORMATION PRIVACY RIGHTS

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain
privacy
rights concerning your health care information. Under this law your health care provider generally
cannot give your information to your employer, use or share your information for marketing or
advertising purposes, or share private notes about your mental health counseling sessions
without your written consent. As one of your health care providers it is our responsibility to keep
your information safe and secure. We also need to make sure that your information is protected in
a way that does not interfere with your health care. It is important that you understand that your
information can be used and shared in the following ways:

_____ For your treatment and care coordination. Multiple health care providers may be involved
in your
treatment directly and indirectly.
_____ With your family, friends, relatives, or others that you identify who are involved in your
health care
or health care bills.
_____ To protect the public’s health, such as reporting when the flu is in your area.
_____To make required reports to the police, such as gunshot wounds.
_____Obtain payment from third party payers.

In order to provide you with service that best meets your privacy needs, please tell us how best to
contact you when needed. Please check all that apply:

_____Please do not phone me at home. Use this alternate phone number: ______________________
_____Please do not phone me at work. Use this alternate phone number: ______________________
_____Please do not leave messages on my answering machine.
_____Please do not contact me by email.
_____Please send mail, including my bills, to this alternate address: _______________________________
_____________________________________________________________________________________
Other request (please describe): __________________________________________________________
_____________________________________________________________________________________




Patient/Guardian Signature________________________________________________Date:_______________________

(If patient is a minor) Patient Name (Please Print):

_________________________________________________________

				
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