Whole Health Clinic 6632 S. 191st Place, Suite E-110; Kent, WA 98032 (425) 656-0700-Fax (425) 656-0705 Date: Name: Age: Birth Date: Gender: MF Address: City: State: Zip: Phone: Home: Can messages be left for you here? YN Work: Can messages be left for you here? YN Cell: Can messages be left for you here? YN Email: Would you like to receive notices from our office?: Occupation: Employer: Single or Married? : Name of Emergency Contact: Phone: (Home)/(cell) How did you hear about us?: Insurance information: Name of the insurance company?: Subscriber's employer?: Subscriber's date of birth?: PLEASE LIST THE HEALTH CONCERN/PROBLEM THAT BRINGS YOU IN TODAY: Problem or diagnosis #1) When did this problem initially start to bother your child? How often does it bother your child—hourly, daily, weekly, monthly? How severe on a scale of zero to 10 (10 being the worst/highest level)? What makes this problem better or worse, namely drugs or supplements, etc.? Anything else important about this problem you’d like to share? Problem or diagnosis #2) When did this problem initially start to bother your child? How often does it bother your child—hourly, daily, weekly, monthly? How severe on a scale of zero to 10 (10 being the worst/highest level)? What makes this problem better or worse, namely drugs or supplements, etc.? Anything else important about this problem you’d like to share? Problem or diagnosis #3) When did this problem initially start to bother your child? How often does it bother your child—hourly, daily, weekly, monthly? How severe on a scale of zero to 10 (10 being the worst/highest level)? What makes this problem better or worse, namely drugs or supplements, etc.? Anything else important about this problem you’d like to share? Problem or diagnosis #4) When did this problem initially start to bother your child? How often does it bother your child—hourly, daily, weekly, monthly? How severe on a scale of zero to 10 (10 being the worst/highest level)? What makes this problem better or worse, namely drugs or supplements, etc.? Anything else important about this problem you’d like to share? Problem or diagnosis #5) When did this problem initially start to bother your child? How often does it bother your child—hourly, daily, weekly, monthly? How severe on a scale of zero to 10 (10 being the worst/highest level)? What makes this problem better or worse, namely drugs or supplements, etc.? Anything else important about this problem you’d like to share? Problem or diagnosis #6) When did this problem initially start to bother your child? How often does it bother your child—hourly, daily, weekly, monthly? How severe on a scale of zero to 10 (10 being the worst/highest level)? What makes this problem better or worse, namely drugs or supplements, etc.? Anything else important about this problem you’d like to share? Please list any prescription or over the counter medications that you are currently taking: Name of DRUG Dose Reason for taking For how long Who prescribed ALLERGIC TO ANY DRUGS OR SUBSTANCES? WHAT?: Please list any vitamins, minerals, herbs or homeopathic remedies that you are presently taking: Please list your current health care providers: Name Type For what reason Phone (if available) Hospitalizations, Serious Illnesses and Injuries: (Please list reason and dates, excluding non-surgical childbirth): Date of last full physical exam: Results: normal other: Date of last blood work: Results: normal other: (Females) Are you pregnant, or is there any chance that you are pregnant?: Do you have any surgical implants? If so, what type and where in your body?: Have you seen a naturopath before? If so, how many other naturopaths have you seen? How long have you been interested in natural medicine? Lifestyle Habits: Tobacco (currently): NoneDailyWeeklyMonthly Amount: Do you any history of smoking? If so, how many years? What years?: Coffee: NoneDailyWeeklyMonthly Amount: Black tea: NoneDailyWeeklyMonthly Amount: Soft drinks: NoneDailyWeeklyMonthly Amount: Alcohol: NoneDailyWeeklyMonthly Amount: History of significant alcohol consumption or alcoholism? How long and how much?: Recreational drugs: NoneDailyWeeklyMonthly Amount: History of significant recreational drug use? Exercise: NoneDailyWeeklyMonthly Amount: Are you currently sexually active? -How would you rate your libido (sex drive) on a scale of zero to 10? Diet: Please describe your typical diet (breakfast, lunch, and dinner), including any guidelines or restrictions that you follow: Breakfast: Lunch: Dinner: (Optional) Please describe briefly your religious and/or spiritual background/beliefs: History of Covid and Covid vaccine: Do you recall when you might have contracted Covid? Approximate date(s) would be fine: Have you received any Covid vaccines? If so, which one(s) and the date(s). Ideally list the exact date(s), but approximate date(s) will be fine too. PATIENT PROFILE (PLEASE ANSWER CAREFULLY.) REVIEW OF SYSTEMS: Y = Now P = Past (a problem in the past) For the following, PLEASE CIRCLE, or fill in blanks. “Y” means you have the condition now. “P” means that you had the condition in the past, but not any more. If you have never had a condition, leave it blank. GENERAL Height: Weight: Weight changes YP Night Sweats YP Fatigue: YP Fever YP MENTAL / EMOTIONAL Depression YP Mood Swings YP Anxiety or nervousness YP Tension YP Suicide thoughts YP Suicide attempts YP SKIN Acne YP Eczema YP Hives: YP Rashes YP Infection YP Growths (such as warts) YP Changes in hair/nails: YP Transdermal skin patches? ENDOCRINE Ever had any thyroid problem YP Heat or cold intolerance YP Hypoglycemia YP Excessive thirst YP Excessive hunger YP Easy weight gain YP HEAD Headache YP Head Injury(such as warts) YP CIRCULATION Deep leg pain YP Cold hands/ feet YP Varicose veins YP EYES Dryness YP Glasses or contacts YP Eye pain YP Tearing YP Double vision YP BLOOD Anemia YP Easy bleeding or bruising YP EARS Impaired hearing YP Ringing (tinnitus) YP Ear ache/itch YP Dizziness YP HEART Heart disease YP High blood pressure YP Rheumatic fever YP Chest pain YP Swelling in ankles YP Palpitations, fluttering YP NOSE & SINUSES Frequent colds YP Nose bleeds YP Stuffiness YP Sinus problems YP Post nasal drip YP RESPIRATORY Cough YP Spitting up blood YP Wheezing YP Difficulty breathing YP Shortness of breath YP Positive TB test ever? YP MOUTH & THROAT Frequent sore throat YP Sore tongue YP Sores in mouth /on lips YP Gum problems YP Hoarseness YP Dental Problems YP Fake teeth? How many? How many amalgam (mercury) fillings? Dental implants? If yes, what type? Dental bridges or partial bridges? If so, are they metallic? Any metal of any kind in your mouth? DIGESTION Trouble swallowing YP Heartburn YP Take heartburn or acid reflux medicines? Bloating after eating YP Change in appetite YP Change in thirst YP Loose stools YP Blood in stools YP Belching or gas YP Liver/gall bladder disease YP Hemorrhoids YP Nausea YP Vomiting YP Bowels move: dailymoreless Use laxatives? What kind? Eat plenty of fiber? URINARY Pain on urination YP Increased frequency YP Frequency at night YP Inability to hold urine YP Bladder infections YP Swellings anywhere in body YP FEMALE Age menses began No. of days menstrual flow Length of complete cycle Are cycles regular YP Bleeding between periods YP Excessive flow YP Cramps YP PMS YP Abnormal vaginal discharge YP DATE of LAST PAP Smear Results were: normal abnormal don't know EVER had an abnormal PAP? YP Date of last mammogram? Ever used birth control pills? YP Ever used an IUD? YP If so, how long? No. of pregnancies No. of live births No. of miscarriages No. of abortions Menopausal symptoms YP Still have your own uterus? Yes or No? Still have your own ovaries? Yes or No? MUSCULOSKELETAL Joint pain or stiffness YP Broken bones YP Muscle spasms or cramps YP Weakness YP Date of last DEXA scan? BREASTS Do you self exam regularly YP Lumps YP Pain or tenderness YP Nipple Discharge YP NEUROLOGIC Fainting YP Seizures YP Paralysis YP Muscle weakness YP Numbness or tingling YP Loss of memory YP NECK Swollen glands YP Pain or stiffness YP Male Hernias YP Testicular masses YP Testicular pain YP Discharge or sores YP Venereal disease YP Difficulty stopping or starting urination YP Prostate problems YP Date of last prostate exam Family History: If you have any significant family medical history, please list them here. Examples: Cancer, heart disease, high blood pressure, diabetes, mental illness, stroke, alcoholism, etc. Please specify if the condition is on your mother's side versus father's side. Problem List: Please list ANY or ALL medical conditions you have EVER been diagnosed with, starting from birth on? Δ
