Microsoft word - new patient questionnaire

Name________________________________ Nickname (If preferred)__________________ Date of Birth___/____/____ Age______ Female / Male Current weight_______ one year ago______ Maximum weight________ Height_________ Drug allergies_______________________________________________________________________________________ Reasons for this visit- please include your most important health concerns in order of significance:
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List ALL Prescription and non-prescription oral, nasal, inhaled and topical medications with dosages as you ACTUALLY
take them (250mg once daily, 100mg twice weekly, 2-3 10mg tablets 3 days a month as needed for pain/headaches, etc) Please include medications like Tylenol, Ibuprofen, Aspirin, Miralax, Nasal Sprays (Nasacort, Flonase, isotonic
saline) skin creams/ointments/gels with the name and percentage of the active ingredient, even if you only use them occasionally. If you run out of space or time or do not understand the labeling - bring all medications with you. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ List ALL supplements, herbs, vitamins, minerals, homeopathics, protein/fiber/green powders as you ACTUALLY take
them. For complex formulas (more than 2 ingredients), include the BRAND and product name or bring the bottle with __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please circle any of the following that you use: Coffee/black tea/cola_____ /day/wk/mo Milk(type_______) Sweetener (type_________) Flavoring(type __________) Alcohol ______/day/wk/mo Wine/Beer/Spirits Recreational drugs_____day/wk/mo (type___________# years____) Nicotine _____/day/wk/mo Cigarettes/Nicotine gum/Patch (_____#/day) Total # years of cigarette smoking________ Dietary regimens or restrictions : gluten-free/wheat-free/dairy-free/vegetarian/vegan__________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Food allergies, sensitivities, diagnosed or suspected:_______________________________________________________ __________________________________________________________________________________________________ Exercise regularly: Yes No Types:______________________________________________________________________
How often?_____________________________________For how long?________________________________________ CIRCLE symptoms you experience regularly. Women: X CHECK if they occur near or with your period where applicable.
__ chocolate __coffee __Alcohol __ other_____ __Excessive sweating __Watery/itchy __Chest pain Sleep Hygiene: Use of sleep aid? Yes No Type____________________ How often?___________________________
(If you use a sleep aid, please fill out according to how you sleep with a sleep aid, then explain in space below how you
sleep without an aid)
# of hours per night of actual sleep on weekdays_______ on weekends______ # of hours ALLOWED for sleep on Weekdays______ on Weekends_______ How long does it take to fall asleep?_______Wake during the night? Yes No
Approx. # of times________ How long awake during these times? Approx. _________ # of times night sweats wake you up_______ #of times you wake needing to urinate______ I only wake up from: family/pets/noise How is your sleep without an aid:_______________________________________________________________________
Use of (Circle) TV/Computer/iPAD/Messaging device before bed or when trying to go to sleep
Room completely dark when going to sleep (circle: street lights, floodlights, nightlights, clock lights)? Yes No
Wear an eye mask/earplugs? Yes No What time do you go to bed?_________ What time do you get up?_________
Menstrual and Reproductive History: (This page, females only)
Age of first period___ Using a birth control method now? Yes No Type?______________________________________
Trying to get pregnant? Yes No #of pregnancies____ #of miscarriages____ #of abortions ____ #of cesareans____
#of ectopic/tubal pregnancies____ #of stillbirths____ #premature deliveries ___#of living children___ Ages_________ What birth control have you used: circle type used in the past, add year and duration: Pill_________ Depo shot______
IUD (Mirena/other________)___________Patch__________ Vaginal ring_________ Emergency contraception________ Problems with any of the methods? Yes No If yes, please explain?__________________________________________
__________________________________________________________________________________________________ Current or past fertility treatment? Yes No Past use of bioidentical hormones? circle all that apply, add year/duration
DHEA____________________ Biest_____________________Estradiol___________________ Estriol________________ Progesterone__________________________ Pregnenolone__________________ Testosterone___________________ __________________________________________________________________________________________________ Have you had a hysterectomy? Yes No Date___________Reason?__________________________________________
Do you still have ovaries? None One Two Uterine Ablation? Yes No Date_________________________________
Circle all that apply, current and past: Fibrocystic breasts Breast cancer Osteoporosis/Osteopenia Lichen Sclerosis
Uterine fibroids Endometrial hyperplasia Endometriosis Ovarian cysts PCOS (polycystic ovarian syndrome) Vaginal yeast infections Bacterial vaginosis Gonorrhea Chlamydia Trichomonas Genital herpes Genital warts Last PAP_______________ Dates of abnormal results: __________________ Dates of treatment ___________________ History of HPV ? Yes No Type_______________ HPV Vaccine? (Gardasil) Yes No
For other PMS or menstrual related symptoms not listed or other unique symptoms, please list them here: __________
__________________________________________________________________________________________________ Menstrual details: Last menstrual period (date of first day of bleeding)___________ or # of years since last period____
Tubal ligation? Yes No Date_________ how many days is your current cycle? (count from the 1st day of bleeding to
the 1st day of bleeding of the next cycle) circle: <20 20-30 30-40 40-50 >50 Is your cycle predictable? Yes no
How many days do you bleed?________ How many heavy days of bleeding?_____ # of tampons and/or pads (circle)
on heavy days___________/______________ on light days _________________/_________________ Color of flow: Bright red Dark red Light red Pink Brown Spotting only (circle) Do you pass clots? Yes No
Size of clots(circle): grainy pea nickel quarter golfball egg lemon How many days do you pass clots?________ Medical History:
Surgeries, hospitalizations, Emergency room visits and other procedures(include approximate dates and chronology): Last: Colonoscopy_________Prostate exam__________ Mammogram___________DEXA___________ EKG___________ _______________________ _______________________ ______________________ ______________________ Current Medical diagnoses: _______________________ _____________________ _______________________
_______________________ _______________________ _____________________ _______________________ _______________________ _______________________ ______________________ ______________________ Personal medical history and Family medical history (blood relatives only):
Self Past Family Relation to you Self Past Family Relation Alcoholism/drug use ___ ___ ___ __________ Anemia ___ ___ ___ ___________ Asthma ___ ___ ___ __________ Allergies ___ ___ ___ ___________ Arthritis ___ ___ ___ __________ Auto-immune disorder ___ ___ ___ ___________ Bladder disease ___ ___ ___ __________ (type________________________________________) Cancer ___ ___ ___ __________ Celiac disease ___ ___ ___ __________ (types_____________________________________) Crohn’s/Colitis ___ ___ ___ __________ Depression ___ ___ ___ __________ Diabetes (Type 1 type 2) ___ ___ ___ ___________ Diverticulosis/itis ___ ___ ___ __________ Epilepsy/Seizures ___ ___ ___ ___________ Gall stones/disease ___ ___ ___ __________ Gum disease ___ ___ ___ __________ Heart Disease ___ ___ ___ __________ High blood pressure ___ ___ ___ __________ Hepatitis A B C (circle)___ ___ ___ ___________ Kidney disease/stones ___ ___ ___ __________ Lung disease ___ ___ ___ ___________ Liver disease ___ ___ ___ __________ Mental disorder ___ ___ ___ __________ Mononucelosis/EBV ___ ___ ___ __________ (type________________________________________) Obesity ___ ___ ___ __________ Rheumatic fever ___ ___ ___ __________ Stroke ___ ___ ___ __________ Suicide attempt(s) #________ ___ __________ Thyroid disease ___ ___ ___ __________ Date(s)_______________________________________ Tuberculosis ___ ___ ___ __________ Tumor ___ ___ ___ ___________ Tumor discovery date________Treatment__________ Other personal and family medical history not listed or previously stated_______________________________________ __________________________________________________________________________________________________ Last dental exam____________ How often do you: Floss_________? See the dentist?______ Metal fillings? Yes No
Gingivitis/periodontal disease? Yes No Root canals? Yes No #_____ Other_____________________________
Immunizations: (circle) DTaP MMR Polio Varicella “Flu” (last ______) Hepatitis B Hib Pneumococcal Other_________ Additional information:_______________________________________________________________________________ __________________________________________________________________________________________________

Source: http://www.seattlenaturopathy.com/forms/patient_profile.pdf