New Patient Intake Form - Dr. Jennifer R. Bitner, ND
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Jennifer R Bitner, BA ND 773-322-6447 drjenbnd@gmail.com Naturopathic Intake Form All questions contained in this questionnaire are strictly confidential and will become part of your medical record Name______________________________________________Date of Birth________________ Address__________________________________City/State/Zip_________________________ Phone___________________________________Email________________________________ List in order of importance your health concerns: 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ Personal History Please list all previous diagnoses for any medical conditions: ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________ What hospitalizations or surgeries have you had? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What diagnostic imaging studies have you had? __X-rays __CT scan __PET scan __MRI __Endoscopy__ Endoscopy___Colonoscopy__ Sigmoidoscopy__Bone density scan __Mammogram__EKG/ECG__ EEG Were there any significant findings? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please list any prescription medications, over-the-counter medications, vitamins, or other supplements you are taking: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are you aware of any allergies to food, drugs, or other environmental allergens (cats, mold, and dust)? If yes, please list and explain:_________________________________________ __________________________________________________________________________ Childhood Illnesses Please circle whether you have/had any of the following conditions as a child/adolescent: Diptheria Mumps Polio Rubella German measles Rheumatic fever Pertussis Chronic Ear or Throat Infections Measles Scarlet Fever Chicken Pox Other _______________________ Past Immunizations Please circle any of the following immunizations you have had. If unsure, please write a question mark beside the immunization. __Diptheria __ Polio __Hepatitis A/ B __Measles/Mumps/Rubella (MMR) __Tetanus __Pertussis__Varicella (Chicken Pox) __ Influenza- annually? Yes / No Other(s)_______________________________________________________________________ Family History Do you have a family history of any of the following (please circle)? Anemia Diabetes Goiter Kidney disease Arthritis Epilepsy Hay fever/hives Liver disease Asthma Gall bladder disease Heart disease Mental illness Cancer Glaucoma Heart murmur Stroke Cataracts Gluten Sensitivity High blood pressure Tuberculosis Is your father still living? Yes; his age ____ No; age at time of death _____ Cause of death _________________________________________________________________________ Is your mother still living? Yes; her age ____ No: age at time of death _____ Cause of death __________________________________________________________________________ Review of Systems Please circle. Y= Yes, present condition P=Problem of the past N=No, never had the condition. Head Headaches Y P N Head injury Y P N Migraine headaches Y P N Jaw/TMJ problems Y P N Ear Ringing Earaches Dizziness\Vertigo Impaired hearing YPN YPN YPN YPN Frequent wax build up Y P N Itchy or moist ears YPN Eyes Blurred vision Eye pain/strain Spots in eyes Nose/Sinuses Stuffiness YPN Hayfever YPN Mouth/Throat Hoarseness YPN Jaw clicks YPN Dry Mouth Y P N Y P N Cataracts Y P N Glaucoma Y P N Color blind YPN YPN YPN Loss of smell Y P N Nose bleeds Y P N Glasses/contacts Tearing/dryness Double vision YPN YPN YPN Sinus problems Frequent discharge YPN YPN Gum problems Dental cavities Y P N Freq. sore throat Y P N Sore lips/tongue YPN YPN Neck Lumps Goiter YPN YPN Swollen glands Pain or stiffness Skin Rashes Lumps Itching YPN YPN YPN Psoriasis Acne, boils Loss of hair Respiratory Asthma Cough Sputum Pleurisy Tuberculosis YPN YPN YPN YPN YPN Wheezing YPN Spitting up blood Bronchitis YPN Difficulty breathing Pneumonia Y P N Pain with breathing Emphysema Y P N Shortness of breath Difficulty breathing while lying down at night Cardiovascular Angina YPN Murmur YPN Fainting YPN Anemia YPN Leg pain YPN YPN YPN YPN Eczema, hives Color changes Night sweats Chest pain YPN Heart disease Y P N Ankle swelling Y P N Cold hands/feet Y P N Easy bruising Y P N YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN Blood clots YPN Rheumatic fever YPN Low/high blood pressure Y P N Thrombophlebitis YPN Varicose veins YPN Gastrointestinal Diarrhea YPN Black stool YPN Hemorrhoids Y P N Abdominal pain Y P N Constipation Coughing up blood Gall bladder disease Blood in stool YPN YPN YPN YPN Ulcers Jaundice Heartburn Liver disease YPN YPN YPN YPN How many bowel movements per day? ______ Are they generally: loose well-formed dry and hard pebble-like Urinary Incontinence Kidney stones YPN YPN Frequent infections Frequency at night Musculoskeletal Joint pain Y P N Muscle spasms YPN Arthritis Y P N Muscle pain/soreness Y P N Sciatica Y P N Muscle weakness YPN Y P N Painful urination Y P N Y P N Change in color / odor Y P N Stiffness YPN Broken bones Y P N Neurological Fainting YPN Seizures YPN Paralysis YPN Loss of memory Y P N Numbness/tingling Muscle weakness YPN YPN Emotional Mood swings Y P N Anxiety YPN Nervousness Y P N Depression Y P N Tension/stressed Loss of loved one YPN YPN Endocrine Hypothyroid Y P N Hyperthyroid Y P N Excessive thirst Excessive hunger YPN YPN Male Reproductive Hernias YPN Testicular masses YPN Prostate issues Y P N Sexual difficulty YPN Premature YPN Sexually transmitted Y P N Ejaculation disease/infections Cold intolerance Heat intolerance YPN YPN Discharge or sores Testicular pain Blood in semen YPN YPN YPN Female Reproductive Age of first menses _________________________ Age of last menses (if menopausal) __________________ Length of cycle _____________________________ Duration of menses _______________________________ Date of last annual exam _____________________ Painful menses Heavy flow Breasts tender Sexually active Sexual difficulty YPN YPN YPN YPN YPN Endometriosis Fertility issues Venereal disease Cycles regular Abnormal pap YPN YPN YPN YPN YPN Ovarian cysts Cervical dysplasia Bleeding between cycles Menopausal symptoms PMS YPN YPN YPN YPN YPN Breast lump(s) Y P N Nipple discharge Y P N Do self breast exams YPN Birth control Y P N If yes, what type? _______________________________________________ Number of pregnancies _______________________ Number of live births_________________ Number of miscarriages _______________________ Number of abortions________________ Environmental Is your home and work environment well ventilated? _______________________________________________________________________ Is your home or work environment excessively damp or moist? _______________________________________________________________________ Has there been any known mold growth, leaks, or large spills in your living or work area? ______________________________________________________________________________ ______________________________________________________________________________ Do you get outdoors daily, even in the winter? ____________________________________________________________________________ How do you feel about your work? Do you enjoy it, are you satisfied and fulfilled by it, does it provide you with the necessities of life, is it just a job you feel you must put in the hours in order to make a living? ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you ever lived in or near an industrial area, waste management area, known environmentally contaminated area? _______________________________________________ ______________________________________________________________________________ Have you ever worked with chemicals, pesticides, solvents, plastics, resins, metals, etc? ______________________________________________________________________________ ______________________________________________________________________________ Do any of your hobbies include the use of chemicals, pesticides, solvents, plastics, resins, metals, etc? ___________________________________________________________________ ______________________________________________________________________________ Is there anything else you would like us know in order to serve you better? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
