Nicole Schertell, ND, CCT
Andrew Chevalier, ND
New Patient Intake Form
Personal Information________________________________________________________________________________
Today’s Date __________________
Name ___________________________________________________________Age _______ DOB:___________________
Phone: H (_____)______________________ W (_____)___________________ Cell (_____)_______________________
Preferred ______ Home ______ Work ______ Mobile
Is it OK to leave messages? _____ yes _____no
Address: ___________________________________________________________________________________________
City, State, Zip:______________________________________________________________________________________
Email Address: ______________________________________________________________________________________
How did you hear about our office? _____________________________________________________________________
If you were referred to us, who may we thank? ___________________________________________________________
Are you interested in receiving email notifications of classes and lectures? _____ yes _____ no
Emergency Contact__________________________________________________________________________________
Name: _________________________________________________________ Relationship: ________________________
Phone # H (
)___________________ W (
)__________________ Cell (
)_______________________
Address: ___________________________________________________________________________________________
City, State, Zip: _____________________________________________________________________________________
Have you been to a Doctor of Naturopathic Medicine before? _______ If yes, when? _____________________________
What were you being treated for? ______________________________________________________________________
__________________________________________________________________________________________________
Were you satisfied with your care? _________ If not, please explain: _________________________________________
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When was the last time you had medical care and for what reason? ___________________________________________
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Name & Phone # of PCP: ______________________________________________________________________________
What are your primary health concerns? List them in order of importance to you:
__________________________________________________________________________________________________
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What is the primary expectation you have for your visit at our clinic today?_____________________________________
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Health History______________________________________________________________________________________
Please list any known allergies (environmental, drug, food, animals, chemicals/perfumes): _________________________
__________________________________________________________________________________________________
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Do you take any of the following over-the-counter medications? Please check any that apply:
___Aspirin
___Ibuprofen or acetaminophen
___Antihistamine
___ Sleeping pills
___Laxatives ___Appetite Depressants
___Antacid
___Medicine to stay awake
Please list any pharmaceutical and/or natural medications (including vitamins) that you are taking or have taken in the last year.
Medication
Dosage
Which diagnostic studies have you had? Please indicate dates:
Hospitalization _____________________________
Surgery ___________________________________
X-ray _____________________________________
MRI ______________________________________
Rectal Exam _______________________________
Electrocardiogram __________________________
Dates
Reason for taking
Endoscopy __________________________________
Colonoscopy _________________________________
Mammogram ________________________________
CT Scan _____________________________________
Bone Scan ___________________________________
Other _______________________________________
For the following conditions and symptoms, please indicate any that apply to you by marking a “C” for current or “P” for
past:
___ Skin rash
___ Chronic pain
___ Difficulty breathing
___ Anemia
___ Fatigue
___ Chest pain
___ Easy bleeding or bruising
___ Weakness
___ Heart palpitations
___ Varicose veins or hemorrhoids
___ Dizziness or fainting
___ Atherosclerosis
___ Bone or joint disease
___ Numbness/tingling/paralysis
___ Gastrointestinal paralysis
___ Mood swings
___ Neurological disease
___ Heartburn
___ Anxiety or nervousness
___ Seizures
___ Gastritis or ulcers
___ Difficulty sleeping
___ Memory loss
___ Excessive thirst/hunger
___ Feel unsafe at home
___ Headaches
___ Hypoglycemia
___ Physical abuse
___ Head injury
___ Eating disorder
___ Frequent antibiotic use
___ Dental problems
___ Parasites
___ Frequent colds or flu
___ Cold sores
___ Liver disease
___ HIV or AIDS
___ Ear infections
___ Gallbladder disease
___ Lyme disease
___ Impaired hearing/vision
___ Kidney disease
___ Rheumatic Fever
___ Sinus problems
___ Problems with urination
___ Vaccinations
___ Thyroid problems
___ Sexual difficulties
When are your symptoms worse?
___ Morning
___ Afternoon
___ At home
___ At work
___ Upon waking
___ Evening
___ Overnight
___ No pattern
___ Other: _________________________________________________________________________________________
__________________________________________________________________________________________________
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Family History______________________________________________________________________________________
If you or anyone in your immediate family has had any of the following conditions, please indicate who was affected (self,
mother, father, sister, brother, child):
Cancer ______________________________________
Diabetes ______________________________________
Heart Disease ________________________________
Asthma, hay fever, rashes ________________________
Stroke ______________________________________
Osteoporosis __________________________________
High blood pressure ___________________________
Depression ____________________________________
Alcoholism or substance abuse __________________
Autoimmune disease ____________________________
Attempted suicide ____________________________
Other ________________________________________
For Men Only_______________________________________________________________________________________
Please check all that apply to you:
___ Prostate exam _____/_____/_____
___ Abnormal discharge from penis
___ Regular self-testicular exam
___ Pain or lump in scrotum
___ Impaired fertility
___ Prostate problem
___ Sexual abuse
___ Sexually transmitted infection
For Women Only____________________________________________________________________________________
Last menses
_____/_____/_____
Please check all that apply to you:
Last pap smear
_____/_____/_____
___ Hysterectomy _____/_____/_____
Age menses began
________
___ Abnormal pap smear
Number of pregnancies
________
___ Breast pain/lump/nipple discharge
Number of live births
________
___ Sexual difficulties
___ Frequent vaginitis/chronic yeast infections
If you are still having periods:
___ Abnormal vaginal discharge
Average number of days of bleeding ________
___ Endometriosis
Average number of days in cycle
________
___ Polycystic ovary syndrome
Bleeding is:
___ Regular
___ Irregular
___ Sexually transmitted infection
___ Light
___ Medium ___ Heavy
___ Pelvic inflammatory disease
Symptoms:
___ Bleeding between periods
___ Uterine fibroids
___ Mood swings
___ PMS
___ Impaired fertility
___ Painful menses
___ Breast tenderness
___ Sexual abuse
___ Regular self-breast exam
If you are no longer having periods:
___ Sexually active
___ Hot flashes
___ Vaginal dryness
___ Use methods to prevent pregnancy and/or sexually
___ Dry skin
___ Changes in memory
transmitted infections:
___ Spotting
___ Changes in libido
Current: ______________________________________
___ Facial hair
___ Changes in mood
Past: _________________________________________
___ Hair loss
___ Hormone replacement therapy
___ Incontinence
___ Urinary tract infections
Lifestyle History_____________________________________________________________________________________
Please check any that apply to you and fill in corresponding details:
___ Exercise ______ hours per week
Height _________________________________
Activities __________________________________________
Weight _________________________________
___ Watch TV ______ hours per week
Weight one year ago ______________________
___ Tobacco use ______ packs per day
Maximum weight ________________________
___ Alcohol ______ drinks per day ______ per week
When? _________________________________
___ Recreational drug use
Sleep __________ hours per night
___ Mercury amalgam fillings
Is this enough? ___ yes ___ no
___ Employed outside the home
# of Meals per day________________________
Occupation ____________________________________
Bowel movements per day _________________
Hours per week ________________________________
Dietary restrictions _______________________
Employer _____________________________________
_______________________________________
Do you enjoy your work? ___ yes ___ no
Level of stress ___ Low ___ Average ___ High
___ Toxic exposure __________________________________________________________________________________
___ Major life change in last year _______________________________________________________________________
__________________________________________________________________________________________________
Dr. Nicole Schertell ND, CCT & Dr. Andy Chevalier
HIPAA CONSENT FORM
I give this practice/clinic my consent to use or disclose my protected health information to
carry out my treatment, to obtain payment from insurance companies, and for health care
operations like quality reviews.
I have been informed that I may review the practice/clinic’s Notice of Privacy Practices (for a
more complete description of uses and disclosures) before signing this consent.
I understand that this practice/clinic has the right to change their privacy practices and that I
may obtain any revised notices at the practice/clinic.
I understand that I have the right to request a restriction of how my protected health
information is used. However, I also understand that the practice/clinic is not required to
agree to the request. If the practice/clinic agrees to my requested restriction, they must follow
the restriction(s).
I also understand that I may revoke this consent at any time, by making a request in writing,
except for information already used or disclosed.
Signature: ______________________________________________ Date: _________________
Patient, parent or legal guardian
If signed by patient representative, state relationship to patient: ________________________