Indian Paintbrush Family Care LLC Dr. McKenzie Steiner, ND E: dr
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Indian Paintbrush Family Care LLC Dr. McKenzie Steiner, ND E: dr.mckenziesteiner@gmail.com P: 307-690-8621 www.drmckenziesteiner.com Patient Information Name:__________________________________________________________________________________ Date of Birth: _________________ Age: ______________________ Sex: ________________ Address: ______________________________________________________________________________ __________________________________________________________________________________________ Phone: ____________________________________ Email: _____________________________________ Preferred method of contact: _______________________________________________________ Occupation: _________________________________________________________________ Emergency Contact: __________________________________________________________________ Health and Lifestyle What are you coming in for today? What expectations do you have for today’s appointment? What are your long-term expectations/goals for your health? What potential obstacles might arise in addressing your health goals? What types of therapies have you tried in addressing your health concerns? 1 Indian Paintbrush Family Care LLC Dr. McKenzie Steiner, ND E: dr.mckenziesteiner@gmail.com P: 307-690-8621 www.drmckenziesteiner.com Medical History Primary care doctor: ________________________________________________________________________ Last medical appointment: _________________________________________________________________ Last labwork: ________________________________________________________________________________ What hospitalizations, surgeries, x-rays, CAT scans, EEGs, EKGs, etc have you had? Year? ________________________________________________________________________________________________ ________________________________________________________________________________________________ Do you have or have you ever had any of the below conditions? ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Alcoholism/Addiction Alzheimer’s Anemia Arthritis Asthma Cancer Dementia Depression Diabetes ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Eating disorder Epilepsy Genetic disorder Glaucoma Hay fever Heart disease High blood pressure Hives Kidney disease ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Learning disabilities Mental illness Migraines Obesity Osteoporosis Parkinson’s Stroke Thyroid disorder Tuberculosis Other relevant medical history?: __________________________________________________________ ________________________________________________________________________________________________ Health Status Height: __________________ Weight: _____________________ Please list any allergies: ___________________________________________________________________ Children: ________________________________________________ 2 Indian Paintbrush Family Care LLC Dr. McKenzie Steiner, ND E: dr.mckenziesteiner@gmail.com P: 307-690-8621 www.drmckenziesteiner.com Medications and dosage: ___________________________________________________________________ _______________________________________________________________________________________________ Supplements and dosage: __________________________________________________________________ _______________________________________________________________________________________________ Major causes of stress: _____________________________________________________________________ Main interests and hobbies: _______________________________________________________________ _______________________________________________________________________________________________ Exercise (if so, how often and what kind of activity): ___________________________________ ________________________________________________________________________________________________ Women Only Are you pregnant? _______________________ Breastfeeding?: ________________________________ Last menstrual period: _____________________________________ Family History ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Alcoholism/Addiction Alzheimer’s Anemia Arthritis Asthma Cancer Dementia Depression Diabetes ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Eating disorder Epilepsy Genetic disorder Glaucoma Hay fever Heart disease High blood pressure Hives Kidney disease ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Learning disabilities Mental illness Migraines Obesity Osteoporosis Parkinson’s Stroke Thyroid disorder Tuberculosis Other relevant family history?: _____________________________________________________________ 3
