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Initial Patient Intake Form

Initial Patient Intake Form



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Published by jpalmes
Dr. Namaya Wholistic Homeopathy Initial Patient Intake Form
Dr. Namaya Wholistic Homeopathy Initial Patient Intake Form

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Published by: jpalmes on Sep 15, 2008
Copyright:Attribution Non-commercial


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When completing this Patient Intake Form, please provide as much detail as you can give as theadditional information is very helpful in understanding your health.Record all food and drink for three days prior to the visit.Bring medical or lab reports that that are relevant and any medicines you are taking. Also, bringyour insurance card.THIS INFORMATION IS PART OF YOUR MEDICAL RECORD, AND BY LAW, CANNOTBE RELEASED OR DISCLOSED WITHOUT YOUR PERMISSION: Name: _______________________________________ M/F: ___ Address: _________________________________ Telephone No. Home: ______________ Work: ______________ Birthdate: _____________ Age: _________ Weight: ______ Ideal Weight: ________ Height: ________ Insurance: __________________ Private Pay: _______________________________ Insurance No: ____________________________ GROUP NO: _____________ Other Medical or Health Providers you have seen within the last 5 years: ___________________________________________________________________ PAYMENT: Payment or insurance billing information is due at the time of initial visit. If youneed to schedule payment or are having difficulty with payment, please contact the provider.I. MEDICAL REASON(S) FOR VISITWhat is the medical reason for your visit? _____________________________________________________________________ How long have your had this condition? _____________________________________________________________________ Current RX/Herbs/Homeopathic Vitamins: _____________________________________________________________________ Significant Health Problems: In chronological order 
 _____________________________________________________________________  _____________________________________________________________________  _____________________________________________________________________  _____________________________________________________________________ ALLERGIES: (Food, MEDICATION, Environmental)Present or Previous:MEDICATION: ____________________________ FOOD: _________________________ ENVIRONMENT: __________________________ OTHER: ________________________ How long have your had them? _____________________________________________________________________ What do you take for them? _____________________________________________________________________ How do your allergies affect you? _____________________________________________________________________ II. REVIEW OF SYSTEMSHeadaches?Location: (front, sinus, temple, etc.How often?When?What makes them better?How makes it worse?Intensity of pain?Days better?Season better?FOR THE FOLLOWING QUESTIONS: Please check off yes or no if you have problems in thefollowing areas. If yes, briefly describe.Sinus: Sinus tenderness?Eyes? Ears? Nose? Throat?Teeth? Bad / sour breath?Fillings? Mercury? Silver? Throat?Thyroid? Chest?Breast? Stomach?Liver? Spleen?Bowel Movements? How often? Consistency?
Gas (flatus)? Rectum?Women: Vaginal Problems? Problem with menstrual flow.Frequency? Menstruation heavy? Light?Contraception use? STD?Men: GenitalTesticular Exam: Prostate:(PSA/PAP)OINTS: Arms: _____ Shoulder: _____ Legs Feet?ADDITIONAL PROBLEMS:___________ III. LIFESTYLEStressStress in your life?Your stress level? Scale of 1 - 10?JoyWhat gives you joy in life?What gives you pleasure in life?Do you have hobbies you enjoy?Do you live alone or with family/friends?Your joy level? 1 - 10?SleepAny difficulty with sleep? Hours do you sleep?Do you awaken refreshed after sleeping?IV. FAMILY HISTORY
Significant Family History of Illness:
MOTHER: Alive:_____ Age:FATHER: Alive _____Age:SIBLINGS: Health: Age:Parents: Smokers?Alcohol or drug use in the family?History of congenital diseases in the family?Where are you in the birth order?What was the environment like as a child? Peaceful? Happy? Tension? Conflicted?Birth: Any unusual problems at birth? Premature? Other?

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