intake - Red Leaf Clinic

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CONFIDENTIAL PATIENT INFORMATION
Name: _________________________________________________________ Age: ______ Sex: M F
Address: __________________________________ / ________________ / _____________/ ________
Street #/PO Box
City
State
Zip code
Telephone: (H) _____________________ (W) ______________________ (M) ____________________
Email: _________________________________ Date of Birth: _______________
Who may I contact in an emergency? Name: ________________________ Phone: ________________
How did you hear about Red Leaf Clinic? __________________________________________________
May I send you an occasional (monthly at most) educational e-mail (I’ll never share your address!)? Y N
HEALTH CONCERNS (Please list, in order of importance, your health concerns followed by how long you
have had each concern or condition:
For example: High blood pressure
5 years
3. ____________________________ _______
1. ____________________________ _______
4. ____________________________ _______
2. ____________________________ _______
5. ____________________________ _______
What do you believe is the cause of condition #1? ____________________________________________
____________________________________________________________________________________
If you have been treated for this condition (by yourself or a doctor), what method or medicine was used?
And what were the results? _______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please check (√) the box for condition #1 above:
□
□
□
□
□
Is getting worse
Is constant
Is worse in the morning
Is worse in the afternoon
Is worse in the evening
□
□
□
□
□
Interferes with school/work
Interferes with sleep
Interferes with movement and / or exercise
Have had this or similar conditions in the past
Notice it more during _______________________
When was your last visit to a doctor’s office, medical clinic or hospital? What was the reason?
____________________________________________________________________________________
Date of last physical exam: ____________ Any abnormal findings? Y N If yes, please explain: ______
____________________________________________________________________________________
Are you currently under the care of a health care practitioner? If yes, please explain: _________________
____________________________________________________________________________________
Date of last dental exam: ___________ Dentist: ______________________________________________
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
1
HEALTH GOALS
Please tell me a bit about your short- and long-term health goals? _______________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What is your present level of commitment to address any underlying causes of your signs and symptoms
that relate to your lifestyle? (Rate from 1 to 10, with 10 being 100% committed.)
1
2
3
4
5
6
7
8
9
10
Do you feel like you have a good support network for when challenges arise as part of the journey? _____
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What behaviors or lifestyle habits do you currently engage in regularly that you believe support your
health? (please list) ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What behaviors or lifestyle habits do you currently engage in regularly that you believe are self-destructive
lifestyle habits? (please list) _____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please tell me a little about what you expect from me as your practitioner so I can try my best to meet your
needs: _______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
MEDICATIONS (Please list all pharmaceutical medication(s) and dosage(s) that you are currently taking.
You can use a separate sheet of paper if it’s easier for you.)
For Example: Lipitor
5 years
4. ____________________________
________
1. ____________________________
10mg/day
________
5. ____________________________
________
2. ____________________________
________
6. ____________________________
________
3. ____________________________
________
7. ____________________________
________
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
2
Are you allergic to any medications? Y
N
If yes, please list: ______________________________________________________________________
What is your reaction to these medications? _________________________________________________
Do you have any other allergies to foods or allergens in your environment (e.g. cats, pollen, etc.)? Y N
If yes, please list: _______________________________________________________________________
Please check (√) any of the following that you take:
□
□
□
□
Antacids (Rolaids, Tums)
Antihistamines (Claritin, Benadryl)
Cortisone (cream or pills)
Cough or cold medications
□
□
□
Diet pills or appetite
suppressants
Laxatives
Oral contraceptives or HRT
□
□
□
Pain relievers (aspirin,
Tylenol, Aleve, Motrin)
Sleeping pills
Thyroid medication
What hospitalizations and/or surgeries have you had? Please indicate their dates:
For example: Gall bladder removal
2002
4. _____________________________ _______
1. _____________________________ ______
5. _____________________________ _______
2. _____________________________ ______
6. _____________________________ _______
3. _____________________________ ______
7. _____________________________ _______
Have you ever had a blood transfusion? Y N If yes, was it ☐ your blood or a ☐ donor’s blood?
What diagnostic imaging studies have you had?
□ Bone Density Scan (DEXA)
□ Electroencephalogram (EEG)
□ Colonoscopy
□ Echocardiogram (Echo)
□ CT Scan
□ Laparoscopy
□ Endoscopy
□ Mammogram
□ Electrocardiogram (ECG/EKG)
□ MRI
□
□
□
□
Positron Emission Tomography
(PET scan)
Ultrasound
X- ray
Other_________________
What immunizations have you had? Please include international travel vaccinations if applicable.
□ Diphtheria
□ Hepatitis A
□ Measles, Mumps, Rubells
□ Diphtheria, Tetanus (DT)
□ Hepatitis B
(MMR)
□ Diphtheria, Tetanus,
□ Hepatitis C
□ Polio - □ inactive (IPV)
Pertussis (DTP)
□ Influenza (flu shot)
□ oral (OPV)
□ Tetanus, single
□ Measles, single
□ Rubella, single
□ Gardasil (HPV)
□ Mumps, single
□ Varicella (Chicken Pox)
□ Haemophilus Influenza, type b
□ Other _______________
If you are a child, are your immunizations current? Y N
If not, please explain: ___________________________________________________________________
Have you had the following childhood illnesses? (√) if you’ve had the illness, or leave blank if you’re
unsure:
□ Chicken pox
□ Measles
□ Scarlet fever
□ Diphtheria
□ Mumps
□ Strep throat
□ German measles
□ Rheumatic fever
□ Other ______________
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
3
SUPPLEMENTS List all homeopathic remedies, herbs, vitamins and minerals, with dosage, that you are
currently taking (You may use a separate sheet of paper if needed.):
For example: Vitamin D3
2,000 IU/day
4. ______________________ ______________
1. ______________________ ______________
5. ______________________ ______________
2. ______________________ ______________
6. ______________________ ______________
3. ______________________ ______________
7. ______________________ ______________
SOCIAL HISTORY
Occupation: _________________________(circle) Full-Time / Part-Time / Student / Retired / Disability
Employer / School _____________________________________________________________________
Are you currently: (circle) Single / Married / Long – term relationship / Widowed / Divorced / Other ______
Name of partner: _________________________ Number of children and ages? ____________________
Have you traveled outside the US? Y N If yes, where? ______________________When? ___________
Please describe your social/emotional support network: ________________________________________
____________________________________________________________________________________
Have you ever been abused or assaulted verbally, sexually, or physically? Y
N
____________________________________________________________________________________
Health Habits
Yes
No
If yes, please explain or give frequency?
Do you exercise?
Do you smoke or chew tobacco? Past or
present use?
Do you drink alcoholic beverages?
Do you use recreational drugs?
Have you ever been treated for drug or alcohol
dependence?
Do you drink coffee, soda, or black tea?
Do you drink “diet” sodas or eat “diet” foods?
Are you familiar with “safe sex practices”?
Do you follow any dietary modifications?
Do you follow a spiritual practice?
Do you have any hobbies or interests? What do
you love to do?
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
4
General Review
Do you…
Yes
No
General Review – cont.
Sleep well?
Current weight?
Wake feeling rested?
Weight one year ago?
Eat three meals daily?
Max. adult weight/Date?
Enjoy your work?
Min. adult weight/Date?
Spend time outside?
Max adult height?
Take vacations?
Best energy level? (What time of day)…
Watch television? Hours/week…
Lowest energy level? (What time of day)…
Read? Hours/week…
Subjectively, do you feel your temperature runs
warm or cool?
Use a computer? Hours/day?...
Are you a morning, afternoon, or night person?
FOOD & DIET
Please describe your typical daily food intake:
Breakfast
Lunch
Dinner
Snacks
Beverages
Water _____/day
Filtered? Y N
Other beverages:
What are your favorite foods? _____________________________________________________________
Do you consider yourself a picky or an adventurous eater? ______________________________________
What flavors do you like?
(Circle)
sweet / salty / bitter / sour / aromatic / spicy
/ bland
Do you follow a certain type of diet? Y N Please explain: _____________________________________
____________________________________________________________________________________
Do you or have you ever had an eating disorder? Y N If yes, please explain: _____________________
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
5
PAST MEDICAL HISTORY
Please mark P (past) or C (current) for any of the following conditions that you or your family members
have had:
Condition
Self
Father
Mother
Sibling(s)
Aunt/
Uncle
Grandparent
Child
ADD/ADHD
Alcoholism
Allergies
Anemia/ Blood Disorder
Anxiety/Depression
Arthritis
Asthma
Autoimmune Disease
Blood Vessel Disorder
Cancer
Chemical Sensitivities
Diabetes
Drug/Other Addiction
Eating Disorder
Epilepsy/Seizures
Gallbladder Disease
Gastrointestinal Disorder
Glaucoma/Cataracts
Gum Disease
Headaches/Migraines
Heart Disease
Heart Murmur
High Blood Pressure
Hypoglycemia
Infertility
Kidney Disease
Liver Disease
Lung Disease
Menstrual Disorder
Mental Illness
Muscular Disorder
Neurological Disorder
Pain, Chronic
Skeletal Disorder
Skin Disorder
Stroke
Thyroid Disorder
Tuberculosis
Ulcer (Gastrointestinal)
Urinary Disorder
Vision Problems
Yeast Infections
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
6
OPTIONAL SECTION: much of this will be discussed in office. You can fill it out before your office
visit, or wait until the visit to discuss the questions below.
Please check (√) the box for any conditions that apply to you specifically - □ for Current, or O for Past:
Blood/ Peripheral Vascular
C P
□ O Anemia
□ O Cold hands/feet
□ O Deep leg pain
□ O Easy bleeding/ bruising
□ O Thrombophlebitis
□ O Varicose veins
Neurologic
C P
□ O Loss of memory
□ O Numbness or tingling
□ O Paralysis
□ O Seizures
□ O Tremor
Cardiovascular
□ O Chest pain/pressure
□ O Fainting/Light-headedness
□ O Low blood pressure
□ O High blood pressure
□ O High cholesterol
□ O Heart beat, irregular
□ O Heart murmur
□ O Palpitations, fluttering
□ O Rheumatic fever
□ O Swelling in ankles
Mental/Emotional
□ O Anxiety, nervousness
□ O Poor memory
□ O Depression
□ O Concentration, difficult
□ O Contemplated suicide
□ O Critical of others
□ O Critical of self
□ O Experience loneliness
□ O Mood swings
□ O Tension, stress
□ O Treatment for mental/
emotional concerns
Endocrine
□ O Fatigue
□ O Heat or cold intolerance
□ O Hypoglycemia
□ O Hypo/hyperthyroid
□ O Increasing hunger
□ O Increasing thirst
□ O Night sweats
□ O Seasonal depression
Neck
□O
□O
□O
□O
Goiter (Enlarged thyroid)
Lumps/Swollen glands
Pain or stiffness
Whiplash injury
Head
□O
□O
□O
□O
Headaches
Head injury
Jaw or TMJ problems
Migraines
Nose and Sinuses
□ O Hay fever
□ O Nose bleeds
□ O Runny nose
□ O Sinus problems
□ O Stuffiness, congestion
Eyes
C P
□O
□O
□O
□O
□O
□
□
□
□
□
□
□
O
O
O
O
O
O
O
Ears
□O
□O
□O
□O
□O
□O
□O
Itchy eyes
Eye pain
Glasses or contacts
Glaucoma
Retinal detachment
Spots in eyes
Tearing, excessive
Dizziness/Vertigo
Earache
Ear infections
Ears, itchy
Hearing, impaired
Ringing, tinnitus
Wax, excessive
Mouth and Throat
□ O Bad breath
□ O Dental cavities/fillings
□ O Dentures
□ O Frequent sore throat
□ O Frequently clearing throat
□ O Gum problems
□ O Hoarseness
□ O Metallic taste in mouth
□ O Mouth sores
□ O Saliva, excess
□ O Sore tongue, lips
□ O Teeth grinding
Blurriness
Cataracts
Color blindness
Diminished night vision
Dryness, excessive
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
7
Respiratory
C P
□ O Asthma
□ O Bronchitis
□ O Cough, chronic
□ O Difficulty breathing
□ O Emphysema
□ O Pain with breathing
□ O Pneumonia
□ O Pleurisy
□ O Shortness of breath
□ O At night
□ O Lying down
□ O With exercise/exertion
□ O Spitting up blood
□ O Sputum
□ O Wheezing
Urinary
□
□
□
□
□
□
□
□
□
□
□
□
O Bed wetting
O BPH (Benign Prostatic
Hypertrophy)
O Frequency at night
O Frequent infections
O Increased frequency
O Inability to hold urine
O Kidney stones
O Kidney, low-back pain
O Low force of urine
O Pain with urination
O Urine retention
O Urgency with urination
Gastrointestinal
Musculoskeletal
C P
C P
□ O Abdominal pain, cramps
□ O Arch supports/heel lifts
□ O Alternating diarrhea/constipation □ O Arthritis
□ O Belching
□ O Back pain
□ O Blood in stool
□ O Broken bones
□ O Change in stool
□ O Joint pain or stiffness
□ O Bowel movements, how often? □ O Joint swelling
(#)___ per day/2days/3 days/week □ O Muscle pain
□ O Bulimia
□ O Muscle spasms/cramps
□ O Change in appetite
□ O Muscle weakness, tiredness
□ O Change in thirst
□ O Osteoporosis/osteopenia
□ O Constipation
□ O Sciatica
□ O Diarrhea
Skin and Hair
□ O Fatigue after eating
□ O Flatulence/gas
□ O Acne
□ O Gallbladder disease
□ O Boils
□ O Heartburn
□ O Cancer
□ O Hemorrhoids
□ O Color change
□ O Hepatitis
□ O Eczema
□ O Jaundice
□ O Flushing/hot flashes
□ O Liver disease
□ O Hair loss
□ O Nausea
□ O Hives
□ O Pain in rectum
□ O Itching
□ O Painful stool
□ O Lumps
□ O Parasites, diagnosed
□ O Moles
□ O Reflux
□ O Psoriasis
□ O Stomach pain
□ O Rashes
□ O Trouble swallowing
□ O Rosacea
□ O Vomiting
□ O Skin Tag(s)
Male Reproductive (if applicable)
Please check (√) the box for any that apply to you:
□
□
□
□
Birth control, what type?
______________
BPH
Ejaculation concerns
Fertility concerns
□
□
□
□
□
Impotence
Penile discharge
Penile sores
Prostate disease
Currently sexually active
□
□
□
□
Sexual difficulties
Sexually transmitted
infection(s): ___________
Testicular masses
Testicular pain
Date of last prostate exam? _____________
Sexual orientation (Circle):
Men / Women / Bisexual
Transgender: Y N
Men, please take a moment to tell me about your Health Goals at the bottom of the next page…
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
8
REPRODUCTIVE, FEMALE
Age of first menses __________
Avg. duration of blood flow _____ (days)
Number of days between menstrual cycles ______ (days)
Are your cycles regular? Y N
Are you pregnant? Y N
Date of last menstrual period _____________
Age of last period (if menopausal) ________
Mother’s age at menopause ___________
Date of last annual exam/PAP _________ Do you do self-breast exams? Y N How often? __________
Please specify number of: Pregnancies _____ Live Births _____ Miscarriages _____ Abortions _____
Sexual orientation (Circle):
Men / Women / Bisexual
Transgender: Y N
Please check (√) the box for any that apply to you:
□
□
□
□
□
□
□
□
□
□
Abnormal PAP
Birth control, what type?
________________
Breast lumps, fibrocystic
changes
Cervical dysplasia
Clots in menstrual flow
Cramping with menses
DES exposure
Difficulty getting pregnant
Endometriosis
Genital warts
□
□
□
□
□
□
□
□
□
□
Heavy menstrual flow
Hormone replacement
therapy
Hysterectomy, oophorectomy
Hysterectomy, ovaries intact
Increased / decreased libido
Irregular cycles
Menopausal symptoms
Nipple discharge
Other
___________________
Ovarian cysts/PCOS
□
□
□
□
□
□
□
□
□
□
Painful intercourse
Painful periods
Premenstrual Syndrome
(PMS)
Scanty menstrual flow
Spotting between periods
Sexual difficulties
Currently sexually active
Sexually transmitted
infection: ______________
Uterine fibroids
Vaginal discharge
Thank you very much for your time and thoughtfulness in completing this detailed health history.
RED LEAF NATURAL HEALTH CLINIC
833 SW 11TH SUITE 1018 PORTLAND OREGON 97205
P(503) 224-2525 F: (503) 224-3397
9
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