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Name:
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Birthday:
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Sex:
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Address:
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Email Address:
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Telephone
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Home:
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Work:
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Cell:
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May we leave messages relating to your visits?
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Emergency contact
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Name:
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Phone number:
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Relation:
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Insurance
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Private Insurer:
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Policy/Group #:
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Member ID/Certificate#:
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Primary Plan Member Name
Date of Birth
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Referral
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How did you hear about our Clinic:
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Referred by:
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Other health care providers you are seeing
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1.
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Phone:
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2.
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Phone:
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3.
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Phone:
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4.
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Phone:
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Do you get regular screening tests done by another doctor? (Pap, blood tests, etc.)?
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If you are female are you currently pregnant?
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Do you have any allergies?
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Food
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Environmental
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Medicine
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What are your health concerns, in order of importance to you:
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1.
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2.
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3.
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4.
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Medical history
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How would you describe your general state of health?
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Please indicate any serious conditions, illnesses or injuries, and any hospitalizations; along with approximate dates.
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ailment 1.
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date:
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ailment 2.
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date:
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ailment 3.
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date:
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ailment 4.
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date:
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Current/past medications
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How many times have you been treated with antibiotics?
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Do you frequently use any of the following?
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AspirinLaxativesAntacidsDiet pillsBirth control pills/implants/injections
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Alcohol - how much
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Tobacco - form and amount/day
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Caffeine - form and amount/day
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Recreational drugs - what and how often
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Please indicate what immunizations you have had
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DPT diphtheria, pertussis, tetanusHaemophilus influenza BHepatitis AFluHepatitis BMMR (measles, mumps, rubella)PolioSmallpox
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Tetanus booster; when?
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Other
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Please indicate if any caused adverse reactions:
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Diet
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Do you have any food intolerances or dietary restrictions (religious, vegetarian/vegan etc.)?
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Intolerances
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Restricitons
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Family history
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Indicate if a close relative (parent, child, sibling) has had any of the following:
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Allergies: who
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Depression: who
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Asthma: who
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Mental illness: who
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Heart disease: who
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Drug abuse: who
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High blood pressure: who
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Alcoholism: who
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Cancer: who
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Kidney disease: who
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Diabetes: who
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Other: who
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I don’t know my family medical history
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YesNo
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Environment
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Occupation
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Hobbies
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Do you exercise regularly?
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What do you do for exercise, how much, how often?
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Are you exposed to significant tobacco smoke (work, home, etc.)?
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Are you frequently exposed to animals (work, pets, etc.)?
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On a scale of 1 to 5 how would you rate the emotional climate of your home? (1 hostile - 5 peaceful)
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On a scale of 1 to 5 how stressful is your work? (1 not at all - 5 very)
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On a scale of 1 to 5 how stressful are other aspects of your life? (1 not at all - 5 very)
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Rate how well you handle these stresses? (1 not well at all - 5 very)
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Is there anything that you feel is important that has not been covered?
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