Patient Intake Form: Part #1
Gateway to Health
NATUROPATHIC MEDICAL CLINIC
Thomas Lee Abshier, N.D.
Margo Diann Abshier, N.D.
Health History Questionnaire Instructions:
Holistic health care and preventive medicine can be best delivered when the physician has a deep understanding of the patient on a physical, mental, emotional, and spiritual level. Such analysis is only possible when you have detailed information about your past and present health issues. Thus, it is requested that the following questionnaire be completed as thoroughly as possible. Any question that seems significant should be answered; and if it is a more complicated than a yes or no answer, please give an explanation, and rate the significance of the symptom with a 1-10 rating. Any question which was not understood should be indicated with a question mark. Ideally this questionnaire should be copied from the web page to a Microsoft Word document. At that point you may type the information into the document next to the question, and email it to firstname.lastname@example.org, or fax it to 503 255 1888.
Date of Intake: _____________
Date of Birth
City, State, Zip
Other Objective Physical Data - Current State:
- Blood Pressure:
- Most recent Chemistry Screen (blood test). When? Please fax a copy. Get release of records if needed from lab/doctor.
- Bowel Movements per day:
- Hours of sleep per night:
- Diet Diary: general listing of types of foods consumed daily: Breakfast, Lunch, Dinner and snacks:
- Current Occupation: hours per week, level of satisfaction in work, important past work history:
- Marriage(s): number, length, number of children, current level of satisfaction in marriage:
- Spouse: his/her occupation, level of support for you pursuing Naturopathic medicine as a therapy:
- Educational Background: High School, college, major, trade schools, mentorships, and individual studies:
- Birth & Development: Where born, raised, how long each place, where do you call home and feel most connected:
- Travel: level of exposure to the world, locations, cultures, local, state, national, international:
- Hobbies: What do you do in your free time? What would you do if you had the time, money, and energy?
- Spiritual background: religion, level of intensity of practice, level of integration into your everyday life:
- Alive (Father / Mother): are they still alive?
- Together: (are they still together):
- Separated/divorced: what was your age when your parents separated/divorced:
- Deceased (Mother/Father): your age when parent(s) died:
- Step Parent: your age when new parent arrived:
- Adopted: your age when you were adopted:
- Raised by: who was your primary care provider (parents, split custody, grandparent, aunt/uncle...)
- Number of siblings: Natural biological, step siblings, adopted siblings, foster siblings:
- Sex of siblings:
- Birth order: what is your order of birth?
- Marital Status: Married, Separated, Divorced, Widowed, Single, LWS (Significant partnership):
- Spouse, Partner, Relatives, Friends, Alone, Parents:
- Next of kin or other to reach in case of an emergency, relationship, phone #:
- List the issues which bother you the most.
- What are your most important health problems?
- List as many as you can in order of importance.
- Indicate intensity of symptoms: 0-10 scale, 0 = least, 10 = most severe.
When and where did you last receive medical or health care? What was the reason?
Family Health Status:
Health: Good, Fair, Poor, age, age of death, medical condition
Family Medical History
Indicate the relative who had each of the following illnesses:
- Heart Disease: High Blood Pressure, Stroke
- Mental Illness: Schizophrenia, Bipolar, Depression, Anxiety, Personality Disorder, Mood Disorder
- Allergies: Asthma, Hay fever
- Genetic Diseases: Hemophilia, Down's, Huntington's, Breast Cancer BRACA gene, color blindness...
Indicate which diseases you contracted, the severity, and age
- Chicken Pox
- German Measles
Serious Disease Syndromes:
- Multiple Sclerosis, Chronic Fatigue, Fibromyalgia, Candidiasis, Toxic Metal poisoning, Cancer, Diabetes, Heart Disease, Stroke, Autoimmune diseases...
Serious Infective Illnesses:
- Mononucleosis, length to resolution, did normal energy return, evidence of chronic EBV infection, antibiotics given during illness?
- Staph infection, skin, repetitive infection?
- Strep Throat, or Strep with Kidney or Heart involvement, Scarlet Fever
- Hepatitis A (food borne): age, severity, ongoing symptoms
- Hepatitis B and/or C, when infected, how, viral load, liver fibrosis level, biopsy, symptoms, liver enzymes, last test
- Tuberculosis: age, treatment
- Pneumonia: age, severity, repetition, treatment
- Various: Polio, Smallpox, Cholera, Yellow Fever, Malaria, Tropical diseases, Typhoid, Pertussis (whopping cough), Diphtheria, Tetanus, AIDS, Chronic Epstein Barr Virus, Herpes Zoster (shingles)
- Intestinal parasites: (traveler's diarrhea), amoebic dysentery, tapeworm, Protozoal infections
Traumas and Injuries:
- Body Impacts: Broken bones, spinal injury/chronic pain, car accidents, bad falls, fights
- Head trauma: significant blows to the head? Ever been knocked out by a fall or blow?
- Wounds: knife, gunshot, machine laceration, amputations
Hospitalization and Surgery
- Emergency hospitalizations or surgeries: appendicitis, kidney stones, heart attack, gallstones...
- Chronic disease: Coronary Bypass, endarterectomy, cataract removal lens implant...
- Any organs removed: appendix, tonsils, gallbladder, uterus, ovaries...
- Elective surgeries: Breast Implants, vasectomy/tubal ligations, liposuction, lasix
Imaging and Special Studies:
For what conditions have you had imaging done?
Polio (Oral or Injection)
Tetanus shot (not antitoxin)
Foods, food additives
MCS - Multiple Chemical Sensitivity (synthetic chemicals: smoke, exhaust, perfumes, detergents, carpet, paint...)
Current Prescriptions and OTC Medications:
Do you take or use the following drugs, and for the relief of what condition?
- Pain relievers (NSAIDS/Excedrin, Naproxin; Narcotics/Vicodin, Percocet)
- Antacids: Alkalinizers (Tums, Alka Seltzer), Histamine blockers/Tagamet, Proton Pump inhibitors/Prilosec
- Corticosteroid drugs
- Appetite suppressants
- Sleeping pills
- Tranquilizers (prescription, non-prescription, recreational, or habitual)
- Thyroid medication
- Other OTC or Prescription medications and condition:
Alternative and Prescription Medications:
Please list vitamins, minerals, herbs, amino acids, special nutrients, food concentrates, or other supplements you are taking:
Types, duration, and frequency of exercise:
Cardiovascular: duration, type, heart rate, frequency of exercise
Flexibility: stretching, balance exercises (ball), gymnastics
Resistance: weights, repetitions, type, frequency, length of training
What are your main interests and hobbies?
Do you exercise? What forms? How often?
Do you eat three meals daily?
Sleep: Length (8 hrs/night, restful, and refreshing)? Dreams? Do you remember your dreams?
Enjoy your work?
Spend time outside? Enjoy nature? 15 minutes per day of sunshine?
Conversation? Friends, family, community, political involvement? Satisfying relationships?
Read? How many hours a day?
Vacations? How often, and how long?
Vices and Toxins:
Sugar: candy, pastries, soft drinks, cookies...
Watch television? How many hours a day?
Use caffeine? type, amount, frequency?
Use tobacco? type, amount, frequency?
Use alcoholic beverages? Frequency and consumption level? Drink to the point of impairment or unconsciousness? Treated for or struggle with alcoholism?
Prescription drug dependence: narcotic pain pills (Vicodin, Percocet...), benzodiazopenes (Valium, Xanax...), barbiturates...
Use recreational drugs? Your drug of choice? Been treated for drug dependence?
Use Pornography? Excessive Gambling? Excessive shopping? Binge eating and purging?