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Gateway to Health
NATUROPATHIC
MEDICAL CLINIC
Thomas Lee Abshier, N.D.
Margo Diann Abshier, N.D.
Patient Intake Form: Part #1
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 naturedox@qwest.net, or fax it to 503 255
1888.
Date of Intake: _____________
Identifying
Information:
Name
Sex
Date of
Birth
Address
City, State, Zip
Home
phone
Business phone
Cell phone
Fax
email
SSN
Physical
Data:
Age:
Height:
Weight:
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.
Personal
History:
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.
Parents:
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...)
Siblings:
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)
Live with:
Spouse,
Partner, Relatives, Friends, Alone, Parents
Next of kin or other to
reach in case of an emergency, relationship, phone
#:
Chief Complaints
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 symptom on 0-10 scale, with 0 = least, and 10 = most
severe.
1.
2.
3.
4.
5.
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
Father
Mother
Brothers
Sisters
Spouse
Children
Family Medical
History
Indicate the relative who had each of the
following illnesses:
Cancer
Diabetes
Heart Disease: High Blood Pressure,
Stroke
Mental Illness: Schizophrenia,
Bipolar, Depression, Anxiety, Personality Disorder, Mood
Disorder
Allergies: Asthma, Hayfever
Genetic
Diseases: Hemophilia, Down's, Huntington's, Breast Cancer BRACA
gene, color blindness...
Childhood
Illnesses:
Indicate which diseases you contracted,
the severity, and age
Mumps
Measles
Chicken Pox
German Measles
Other
Serious Disease
Syndromes:
Multiple Sclerosis, Chronic Fatigue,
Fibromyalgia, Candidiasis, Toxic Metal poisoning, Cancer, Diabetis, 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, Diptheria, Pertussis (whopping
cough), Diptheria, Tetanus, AIDS, Chronic Epstein Barr Virus, Herpes
Zoster (shingles)
Intestinal parasites: (traveler's diarrhea), amoebic
dysentary, tapeworm, protazoal 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?
X-rays
CAT
scan
MRI
Ultrasound
EKG: Electrocardiogram
EEG: Electroencephalogram
Immunizations:
Polio (Oral or
Injection)
Pertussis
Tetanus shot (not antitoxin)
Diphtheria
Measles/Mumps/Rubella
Hepatitis
Chickenpox
Other
Allergies:
Foods, food
additives
Drugs
Contact allergens
Airborne allergens
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?
Laxatives
Pain
relievers (NSAIDS/Excedrin, Naproxin; Narcotics/Vicodin,
Percoset)
Antacids: Alkalinizers (Tums, Alkaseltzer), 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:
1.
2.
3.
Alternative and
Prescription Medications:
Please list vitamins,
minerals, herbs, amino acids, special nutrients, food
concentrates, or other supplements you are taking:
1.
2.
3.
Exercise:
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
Healthy Habits
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,
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, Percoset...), 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?
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