File - Krista Dawn Poulton
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Krista Dawn Poulton Medical Herbalist Confidential Patient Intake Form Personal Information: Name: ____________________________ Date of Birth: _____________________ Gender: M / F Is this same gender you were born? ____ Height: ________ Age: ______ Weight: _______ Address: ___________________________________ Occupation: _________________________ ___________________________________ ___________________________________ Phone: ___________________________________ Email: ___________________________________ Emergency Contacts: Emergency Contact 1: Name: _________________________ Relation: _________________________ Phone: _________________________ (cell): _________________________ Email: _________________________ Emergency Contact 2: Name: _________________________ Relation: _________________________ Phone: _________________________ (cell): _________________________ Email: _________________________ Physician (s) Information: Name: _________________________ Name: _________________________ Phone: _________________________ Phone: _________________________ Last Physical Exam: _______________________________________________________ Have you been treated by other health care practitioners for managing presenting symptom? (Phytotherapists, Acupuncturists, Traditional Chinese Medicine Practitioners, etc) Name: _________________________ Phone: _________________________ Modality: _________________________ Name: _________________________ Phone: _________________________ Modality: _________________________ What is Phytotherapy? Phytotherapy is using plants in their natural form, either in tea, tincture or infused oil to support people on their healing journey. Herbalists utilize the seed, root, leaf, bark or flower in either a tincture, tea or infused oil. Herbal medicine addresses the root of the imbalance in an individual, not just the symptoms that are presenting themselves. The goal is to stimulate the individuals innate healing power by teaching your body how to heal and how to defend itself. Therefore the goal of herbal medicine is therefore not to prescribe a herb for an indefinite amount of time but to increase the body's own ability to thrive. Krista Dawn Poulton Medical Herbalist Medical Information: Health Concerns: (reason for your visit today) (Please note onset of symptoms, duration, intensity) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Current Medical History: (Please note any disability under diagnosis) (Note this section is just for ongoing/current conditions) Diagnosis by GP: ________________________ Diagnosis by GP: _________________________ Date of Diagnosis: ________________________ Date of Diagnosis: _________________________ Diagnosis by GP: ________________________ Diagnosis by GP: _________________________ Date of Diagnosis: ________________________ Date of Diagnosis: _________________________ Other:_____________________________________________________________________________ __________________________________________________________________________________ Past Medical History: (please check all the apply) AIDS Alcoholism Allergies Anemia Anorexia Appendicitis Asthma Bleeding Disorder Bronchitis Bulimia Cancer Candidiasis Cataracts Chicken Pox Chronic Pain Convulsions Depression Diabetes Eczema Emphysema Epilepsy Gallbladder Problems German Measles Family History Arthritis Asthma Cancer Depression Diabetes Drug Dependencies Goiter Gout Heart Disease Hepatitis A Hepatitis B Hepatitis C Hernia Herpes simplex 1 Herpes simplex 2 High Blood Pressure High Cholesterol Hyperglycemia Hypoglycemia Jaundice Kidney Disorders Liver Disorders Low Blood Pressure Lupus Measles Menstrual Disorders Migraines Miscarriage Mononucleus Multiple Sclerosis Mumps Obsessive Compulsive Disorder Osteoarthritis Osteoporosis Osteomalacia Parkinson's Polio Prostate Disorders Psoriasis Psychiatric Care Rheumatic Fever Rheumatoid Arthritis Seizures Stomach Ulcers Stroke Thyroid Disorders Tonsillitis Tuberculosis Urinary Tract Infections Venereal Disease Other _____________ Heart Disease High Blood Pressure Kidney Disease Liver Disease Obesity Stroke Other ____________ Other ____________ Krista Dawn Poulton Medical Herbalist Allergies: (please note duration) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Do you have need for an Epi-Pen?_______ Do you actively carry an EpiPen? __________ Surgeries: (Please note date) __________________________________________________________________________________ __________________________________________________________________________________ Hospitalizations: (Please note circumstances and duration of stay) __________________________________________________________________________________ __________________________________________________________________________________ Medications/Supplementation/Herbs: (Please note dosage) Prescribed: (By GP or other health care practitioner) __________________________________________________________________________________ __________________________________________________________________________________ Over the Counter: (example Aspirin, supplements/herbs from Health Food Store) __________________________________________________________________________________ __________________________________________________________________________________ Lifestyle: Habits: (Frequency and amount) Alcohol ____________________________ Caffeine ____________________________ Recreational Drugs ___________________ Tobacco: Current ________________________ Past __________________________ Second hand ____________________ Diet: (Brief summary) __________________________________________________________________________________ __________________________________________________________________________________ Food allergy/sensitivities: __________________________________________________________________________________ __________________________________________________________________________________ Exercise: Daily 3-4x/week 1-2x/week not at all Describe your typical exercise routine: __________________________________________________________________________________ __________________________________________________________________________________ Please list hours spent with per week: Television: ______________________ Computer (personal):____________________________ Computer (work): ______________________________ Krista Dawn Poulton Medical Herbalist Symptoms (Please check all that apply and onset of each) General: Insomnia Dream disturbed sleep Nightmares Excessive sleep Dizziness Numbness Frequent chills Fatigue Premature hair loss Premature greying Respiratory Cough Dry Cough Cough with phlegm Cough with blood Asthma Shortness of Breath Common Cold Excessive Phlegm Circulatory Cold hands and feet Excessive Bleeding Easy Bruising Cardiovascular/Chest Chest pains/tightness Palpitations Irregular Heartbeat Rapid Heart Rate Blood Clotting Disorder Right-sided Rib Pain Burning or tingling sensation Digestive/Excretory Nausea Vomiting Diarrhea Loose stools Constipation No daily bowel movement Haemorrhoids Rectal Pain Excessive Hunger Loss of appetite Weight Loss Weight Gain Abdominal bloating/gas Belching Acid Reflux Hiccups Stomach Pain Abdominal Pain Food allergies/sensitivities Nervous System Tremors Poor Balance Seizures Loss of consciousness Musculoskeletal Note: if unilateral/bilateral & symmetrical/assymetrical Muscle cramps Body aches Joint pain Swollen joints Paralysis Neck and shoulder tension Hand and arm pain Foot and ankle pain Low back pain Upper back pain Mental/Emotional Depression Easily Stressed Anger Irritability Frequent sighing Fear Grief Worrying Anxiety Forgetfulness Cloudy thinking Obsessive behaviour Lack of motivation Nervous tics Abuse survivor Head and Face Headache Migraines Jaw Pain Facial Paralysis Dizziness Mouth and Throat Sore throat Hoarse voice Difficulty swallowing Mouth Ulcers Dry mouth/throat Excessive thirst Lack of thirst Teeth Pain Gum Problems TMJ Eyes Degenerating Vision Blurry Vision Night Blindness Visual Spots Red Eyes Eye pain Nose Sinusitis Nasal Polyps Post-nasal drip Nose Bleeds Nasal Discharge Poor sense of smell Ears Ringing in ears Poor hearing Earaches Ear infection Skin Eczema Psoriasis Hives Acne Fungal Infections Itchy skin Shingles Dry skin Dandruff Excessive sweating No sweating Numbness Urinary/Genital Urinary tract infections Kidney stones Urinary incontinence Frequent nighttime urination Painful urination Dribbling urination Foamy urine Bloody urine Genital Pain Genital itching Venereal diseases Men's Health Impotence Infertility Seminal emissions Premature ejaculation Decreased libido Krista Dawn Poulton Women's Health Painful Intercourse Infertility Endometriosis Vaginal Dryness Medical Herbalist Decreased Libido Other ___________ Menstruation: How many days between periods? ______ Please indicate if you experience any of the following between periods: Vaginal discharge Bleeding Cramps/Pain How many days in duration are your periods? _______ Please indicate quality of blood: Light red Bright red Dark red Clotted Other_________________ Other_________________ Please indicate the quantity of blood: Heavy flow Normal flow Scanty flow Has the volume recently changed? _________ if yes how so: _____________________ If you experience any cramping, please indicate when? Before menstruation During menstruation Do you experience breast tenderness? Y / N When? ________________________________ After menstruation Where?______________________________________ Pregnancy: How many pregnancies have you had? ____________ Have you had any miscarriages? Y / N Have you ever given birth? Y/N If yes, what type of birth was it: ____________________________________ Date of birth: ______________________ Are you currently pregnant? Y/N Are you trying to become pregnant? Y / N Are you currently using contraceptive(s) Y / N If yes, what type and for how long: _____________________________ Menopause: Please indicate your current status: Premenopausal Perimenopausal If applicable, at what age did menopause begin? _______ Please indicate any menopaus-related symptoms: Hot flashes Vaginal Dryness Night sweats Insomnia Postmenopausal Mood Swings Depression Additional Information: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Patient Signature: ________________________________ Guardian Signature: ______________________________ (If patient is under 16 years old) Date: ________________
