Ccnm adult patient profile

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					CHAMPLAIN CENTER FOR NATURAL MEDICINE
Adult Patient Profile
Last Name: _______________________________ First Name: _______________________ Nickname: __________________________ Date of Birth: ______________ MI: ____ Age: ______ Sex: _____

Present Health Concerns Please list your health concerns in order of priority, including date of onset and severity of symptoms. 1. _____________________________________________________________________________________ 2. _____________________________________________________________________________________ 3. _____________________________________________________________________________________ 4. _____________________________________________________________________________________ 5. _____________________________________________________________________________________ What do you believe is causing your most important health concerns? _______________________________ _______________________________________________________________________________________ What goals do you have for your visit today? ___________________________________________________ _______________________________________________________________________________________ Healthcare Practitioners: Please list your current medical practitioners with their contact information. Practitioner’s Name Primary Care OB/Gyn Specialist Therapist Other Pharmacy Medications: Please list any prescription drugs, over-the-counter medications and supplements (vitamins, minerals, nutrients, herbs, homeopathic remedies, etc.) you are currently taking. Medication/Supplement Reason Date began Dose Office Name City Phone

Allergies: Please list and describe any severe or life-threatening allergies (medications, stings, foods, etc.): ________________________________________________________________________________ (OVER) 3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401

Review of Systems: Check  symptoms that you currently experience. Constitutional Max weight: _____ Year: ____ Min weight: ______ Year: ____  Appetite change  Weight change Fevers or Chills Sweats Feel hot or cold Fatigue Weakness Eyes  Eye pain  Poor night vision  Glasses or Contacts Near or Far sighted  Blurred or Double vision  Cataracts  Dry eyes Ears, Nose, Mouth, Throat  Ringing in ears  Earaches  Itchy ears  Excessive ear wax  Hearing loss or hearing aid  Nosebleeds  Stuffy or Runny nose  Postnasal drip  Sinus problems  Change in taste or smell  Teeth / Gum problems  Grinding teeth  Dentures  Mouth sores  Dry mouth  Sore throat  Hoarseness  Jaw clicking or pain  Facial pain Immune System  Frequent infections  Allergies to food  Allergies to environment  Lymph gland swelling / pain                     Heart & Circulation Heart murmur Irregular heartbeat Chest pain Heart palpitations     Digestion & Intestine Bad breath Excessive thirst Difficulty swallowing Indigestion WOMEN: Reproductive Age period started: _______ Length of cycle: _______ days Length of flow: _______ days Last menstrual period: _______ # Pregnancies: _______ # Live births: _______ # Miscarriages: _______ # Abortions: _______ Last pap smear: ___________ Last mammogram: _________  Irregular menstrual cycle  Bleeding between periods  Heavy periods  Painful periods  Premenstrual syndrome  Pelvic pain  Abnormal pap smear  Vaginal discharge  Vaginal itching or soreness  Sores on genitals  Infertility  Sexual difficulties  Pain with intercourse  Menopausal symptoms  Hormone Replacement MEN: Reproductive  Sores on genitals  Discharge  Testicle lump/swelling/pain  Prostate problems  Infertility  Sexual difficulties  Self testicular exam Bladder & Kidney  Waking to urinate  Loss of bladder control  Frequent / Urgent urination  Interrupted flow  Recurrent infections  Painful urination  Blood or pus in urine  Kidney stones

Lightheaded Fainting Blood clots Deep leg pain on walking Varicose veins Swelling of feet / ankles Cold hands / feet Anemia Easy bruising Bleeding tendency Blood transfusions Chest & Lungs  Shortness of breath At rest Walking Lying down  Wheezing or asthma  Cough: wet or dry  Breast lump or pain  Nipple discharge  Self breast exams Neurological  Dizziness  Poor balance  Poor coordination  Tremors or shaking  Seizures  Headaches  Migraines  Numbness or tingling  Nerve pain  Memory loss  Poor concentration  Changes in speech Mental / Emotional  Mood swings  Anger, frustration, irritability  Sadness or anxiety  Phobias  Insomnia or disrupted sleep

 Belching  Heartburn / Reflux  Nausea  Vomiting  Abdominal pain or cramping  Gas or Bloating # Bowel movements/ day: ____  Constipation  Loose stools or Diarrhea  Mucus in stool  Blood in stool  Rectal pain/itching  Hemorrhoids  Hernia  Jaundice Muscles, Bones & Joints  Neck pain  Back pain  Muscle pain  Joint Pain: indicate R or L  wrist  fingers  elbow  shoulder  hip  knee  ankle  foot  Joint swelling  Morning stiffness: ___hours  Joint replacements  Muscle weakness  Muscle cramps Skin, Hair, Nails  Acne  Rashes  Itching or hives  Dry skin or eczema  Moles or growths  Poor wound healing  Hair loss  Nail problems

3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401

 Other:

 Other:

3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401

Past Medical History: Please list the date of or age at each event and describe: Serious Illnesses and Injuries: _______________________________________________________________ Surgeries: ______________________________________________________________________________ Hospitalizations: _________________________________________________________________________ Date of last physical/annual exam: ________________________ Date of last blood tests: _____________

Childhood Illnesses: Please check all that apply. Your health as a child was:  Good  Fair  Poor  Chicken Pox  Mononucleosis (Mono)  Rheumatic Fever  Diphtheria  Mumps  Tonsillitis  Ear Infections  Pertussis (whooping cough)  Scarlet Fever  German Measles (Rubella)  Pneumonia  Strep Throat (recurrent)  Measles  Polio Personal and Family Medical History: Please check the  box next to each condition that applies to you or one of your biological family members. YOU Mom Dad PGM Grandparents PGF MGM Siblings MGF

Current Age or Age at Death Alcohol / Drug Abuse Allergies or Hay Fever Alzheimer’s or Dementia Anemia Anxiety / Panic Attacks Arthritis / Joint Disease Asthma Autoimmune Disease Bleeding Disorder Cancer (what type?) Celiac Disease Crohns Dis / Ulcerative Colitis COPD / Emphysema Depression / Suicide attempt Diabetes Eczema Epilepsy or Seizures Glaucoma Gall Bladder Disease Migraines / Headaches Heart Attack Heart Disease High Blood Pressure High Cholesterol HIV / AIDS Kidney Disease Liver Disease / Hepatitis Osteoporosis Schizophrenia Stroke Thyroid disorder Other: 3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401

Social History Marital status:  Single  Married  Divorced  Widowed  Significant Other Do you have any children?  Yes  No Please list their age(s): ___________________________________ Household:  Alone  Roommate(s)  Spouse/Significant other  Children  Grandchildren  Parent Education level: High school  College  Professional school  Other: _________________________ Occupation:  Student  Work  Homemaker  Unemployed  Volunteer  Retired School/Occupation(s): ________________________________________ Hours per week: _______________ Memories of your childhood:  Mostly happy  Mostly painful  Normal  Don’t recall Do you find your life:  Unsatisfactory  Too demanding  Boring  Satisfactory  Wonderful Lifestyle and Personal Habits: What are your primary sources of stress? _______________________________________________________ How much does stress impact your life? ____________________ Hours of play/relaxation per week? ______ How do you manage stress and take care of yourself? _____________________________________________ Are you: Currently sexually active?  Yes  No Partners: # __  Male  Female Contraception: ______ Satisfied with your sex life?  Yes  No If no, why? ______________________________________ Satisfied with your social life?  Yes  No If no, why? ______________________________________ Satisfied with your spiritual life?  Yes  No If no, why? ______________________________________ Do you: Enjoy your job?  Yes  No If no, why? ______________________________________ Exercise regularly?  Yes  No If no, why? ______________________________________ Which activities? ___________________________________________________________________ Sleep soundly and wake rested?  Yes  No If no, why? ______________________________________ Smoke cigarettes?  Yes  No  Quit ______ How many years? _____ Packs /day? ____ Drink alcohol?  Yes  No  Quit ______ Type? ___________ Drinks per week? ___ Use recreational drugs?  Yes  No  Quit ______ Which? __________ How often? _______ Drink caffeinated beverages?  Yes  No Type? _______________ Drinks per day? ____________ Diet: Please describe your typical meals. Breakfast Time:_______ Lunch Time:_______ Dinner Time:_______ Snacks Times:________

Do you have any dietary restrictions? __________________________________________________________ How often do you eat out? __________________ What are your food cravings? ______________________ Water: ________ oz. per day Other beverages: ____________________________________________ What else would you like us to know about you?

This form has been reviewed by the doctor with the patient.

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Signature of Patient Date

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Signature of Doctor Date

3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401