CHAMPLAIN CENTER FOR NATURAL MEDICINE
Adult Patient Profile
Last Name: _______________________________ First Name: _______________________
Nickname: __________________________
Date of Birth: ______________
MI: ____
Age: ______ Sex: _____
Present Health Concerns
Please list your health concerns in order of priority, including date of onset and severity of symptoms.
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
4. _____________________________________________________________________________________
5. _____________________________________________________________________________________
What do you believe is causing your most important health concerns? _______________________________
_______________________________________________________________________________________
What goals do you have for your visit today? ___________________________________________________
_______________________________________________________________________________________
Healthcare Practitioners: Please list your current medical practitioners with their contact information.
Practitioner’s Name
Office Name
City
Phone
Primary Care
OB/Gyn
Specialist
Therapist
Other
Pharmacy
Medications: Please list any prescription drugs, over-the-counter medications and supplements (vitamins,
minerals, nutrients, herbs, homeopathic remedies, etc.) you are currently taking.
Medication/Supplement
Reason
Date began
Dose
Allergies: Please list and describe any severe or life-threatening allergies (medications, stings, foods, etc.):
________________________________________________________________________________ (OVER)
3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401
Review of Systems: Check  symptoms that you currently experience.
Constitutional
Max weight: _____ Year: ____
Min weight: ______ Year: ____
 Appetite change
 Weight change
Fevers or Chills
Sweats
Feel hot or cold
Fatigue
Weakness
Eyes
 Eye pain
 Poor night vision
 Glasses or Contacts
Near or Far sighted
 Blurred or Double vision
 Cataracts
 Dry eyes
Ears, Nose, Mouth, Throat
 Ringing in ears
 Earaches
 Itchy ears
 Excessive ear wax
 Hearing loss or hearing aid
 Nosebleeds
 Stuffy or Runny nose
 Postnasal drip
 Sinus problems
 Change in taste or smell
 Teeth / Gum problems
 Grinding teeth
 Dentures
 Mouth sores
 Dry mouth
 Sore throat
 Hoarseness
 Jaw clicking or pain
 Facial pain
Immune System
 Frequent infections
 Allergies to food
 Allergies to environment
 Lymph gland swelling / pain
 Other:
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Heart & Circulation
Heart murmur
Irregular heartbeat
Chest pain
Heart palpitations
Lightheaded
Fainting
Blood clots
Deep leg pain on walking
Varicose veins
Swelling of feet / ankles
Cold hands / feet
Anemia
Easy bruising
Bleeding tendency
Blood transfusions
Chest & Lungs
 Shortness of breath
At rest Walking Lying down
 Wheezing or asthma
 Cough: wet or dry
 Breast lump or pain
 Nipple discharge
 Self breast exams
Neurological
 Dizziness
 Poor balance
 Poor coordination
 Tremors or shaking
 Seizures
 Headaches
 Migraines
 Numbness or tingling
 Nerve pain
 Memory loss
 Poor concentration
 Changes in speech
Mental / Emotional
 Mood swings
 Anger, frustration, irritability
 Sadness or anxiety
 Phobias
 Insomnia or disrupted sleep
 Other:
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Digestion & Intestine
Bad breath
Excessive thirst
Difficulty swallowing
Indigestion
 Belching
 Heartburn / Reflux
 Nausea
 Vomiting
 Abdominal pain or cramping
 Gas or Bloating
# Bowel movements/ day: ____
 Constipation
 Loose stools or Diarrhea
 Mucus in stool
 Blood in stool
 Rectal pain/itching
 Hemorrhoids
 Hernia
 Jaundice
Muscles, Bones & Joints
 Neck pain
 Back pain
 Muscle pain
 Joint Pain: indicate R or L
 wrist
 fingers
 elbow
 shoulder
 hip
 knee
 ankle
 foot
 Joint swelling
 Morning stiffness: ___hours
 Joint replacements
 Muscle weakness
 Muscle cramps
Skin, Hair, Nails
 Acne
 Rashes
 Itching or hives
 Dry skin or eczema
 Moles or growths
 Poor wound healing
 Hair loss
 Nail problems
 Other:
WOMEN: Reproductive
Age period started: _____ yrs
Length of cycle: _______ days
Length of flow: _______ days
Last menstrual period:
_______
# Pregnancies: _______
# Live births: _______
# Miscarriages: _______
# Abortions: _______
Last pap smear: ___________
Last mammogram: _________
Last Bone scan: ___________
 Irregular menstrual cycle
 Bleeding between periods
 Heavy periods
 Painful periods
 Premenstrual syndrome
 Pelvic pain
 Abnormal pap smear
 Vaginal discharge
 Vaginal itching or soreness
 Sores on genitals
 Infertility
 Sexual difficulties
 Pain with intercourse
 Menopausal symptoms
 Hormone Replacement
MEN: Reproductive
 Sores on genitals
 Discharge
 Testicle lump/swelling/pain
 Prostate problems
 Infertility
 Sexual difficulties
 Self testicular exam
Bladder & Kidney
 Waking to urinate
 Loss of bladder control
 Frequent / Urgent urination
 Interrupted flow
 Recurrent infections
 Painful urination
 Blood or pus in urine
 Kidney stones
3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401
Past Medical History: Please list the date of or age at each event and describe:
Serious Illnesses and Injuries: _______________________________________________________________
Surgeries: ______________________________________________________________________________
Hospitalizations: _________________________________________________________________________
Date of last physical/annual exam: ________________________
Date of last blood tests: _____________
Childhood Illnesses: Please check all that apply. Your health as a child was:  Good  Fair  Poor
 Chicken Pox
 Mononucleosis (Mono)
 Rheumatic Fever
 Diphtheria
 Mumps
 Tonsillitis
 Ear Infections
 Pertussis (whooping cough)
 Scarlet Fever
 German Measles (Rubella)
 Pneumonia
 Strep Throat (recurrent)
 Measles
 Polio
Personal and Family Medical History:
Please check the  box next to each condition that applies to you or one of your biological family members.
YOU
Mom
Dad
PGM
Grandparents
PGF MGM
Siblings
MGF
Current Age or Age at Death
Alcohol / Drug Abuse
Allergies or Hay Fever
Alzheimer’s or Dementia
Anemia
Anxiety / Panic Attacks
Arthritis / Joint Disease
Asthma
Autoimmune Disease
Bleeding Disorder
Cancer (what type?)
Celiac Disease
Crohns Dis / Ulcerative Colitis
COPD / Emphysema
Depression / Suicide attempt
Diabetes
Eczema
Epilepsy or Seizures
Glaucoma
Gall Bladder Disease
Migraines / Headaches
Heart Attack
Heart Disease
High Blood Pressure
High Cholesterol
HIV / AIDS
Kidney Disease
Liver Disease / Hepatitis
Osteoporosis
Schizophrenia
Stroke
Thyroid disorder
Other:
3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401
Social History
Marital status:  Single  Married  Civil Union  Divorced  Widowed  Significant Other
Do you have any children?  Yes  No Please list their age(s): ___________________________________
Household:  Alone  Roommate(s)  Spouse/Significant other  Children  Grandchildren  Parent
Education level: High school  College  Professional school  Other: _________________________
Occupation:  Student  Work  Homemaker  Unemployed  Volunteer  Retired  Disability
School/Job(s): ______________________________________________ Hours per week: _______________
Memories of your childhood:  Mostly happy  Mostly painful  Normal  Don’t recall
Do you find your life:  Unsatisfactory  Too demanding  Boring  Satisfactory  Wonderful
Lifestyle and Personal Habits:
What are your primary sources of stress? _______________________________________________________
How much does stress impact your life? ____________________ Hours of play/relaxation per week? ______
How do you manage stress and take care of yourself? _____________________________________________
Are you:
Currently sexually active?
Yes No Partners: # ___ Male Female Contraception: _______
Satisfied with your sex life?
Yes No If no, why? ________________________________________
Satisfied with your social life?
Yes No If no, why? ________________________________________
Satisfied with your spiritual life? Yes No If no, why? ________________________________________
Do you:
Enjoy your job?
Yes No If no, why? ________________________________________
Exercise regularly?
Yes No If no, why? ________________________________________
Which activities? ___________________________________________________________________
Sleep soundly and wake rested? Yes No If no, why? ________________________________________
Smoke cigarettes?
Yes No Quit date _______ Total years: ______ Packs /day: ______
Drink alcohol?
Yes No Quit date _______ Type: _________ Drinks /week: ______
Use recreational drugs?
Yes No Quit date _______ Type: ___________ How often: ______
Drink caffeinated beverages?
Yes No Type? __________________________ Drinks /day: ______
Diet: Please describe your typical meals.
Breakfast
Time:_______
Lunch
Time:_______
Dinner
Time:_______
Snacks
Times:________
Do you have any dietary restrictions? __________________________________________________________
How often do you eat out? __________________ What are your food cravings? ______________________
Water: ________ ounces per day
Other beverages: ____________________________________________
What else would you like us to know about you?
This form has been reviewed by the doctor with the patient.
____________________________________
____________________________________
Signature of Patient
Signature of Doctor
Date
Date
3804 Shelburne Road, Shelburne, VT 05482 • Phone (802) 985-8250 • Fax (802) 985-3401