Adult Intake Form test - Natural Medicine Bellevue, Kent

Whole Health Clinic
6632 S. 191st Place, Suite E-110; Kent, WA 98032
(425) 656-0700 â 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 here? YN

Cell:

Can messages be left 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?:

Subscriberâs employer?:

Subscriberâs date of birth?:

Present Health Concerns: Please list your most important health concerns in their order of significance:

Problem or diagnosis #1):

When did this problem initially start to bother you?:

How often does it bother you- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, including drugs or supplements, etc.?

Anything else important about this problem youâd like to share? :

Problem or diagnosis #2)

When did this problem initially start to bother you?

How often does it bother you- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, including drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #3) :

When did this problem initially start to bother you?

How often does it bother you- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, including drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #4)

When did this problem initially start to bother you?

How often does it bother you- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, including drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #5)

When did this problem initially start to bother you?

How often does it bother you- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, including drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #6)

When did this problem initially start to bother you?

How often does it bother you- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, including drugs or supplements, etc.?

Anything else important about this problem youâd 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. âYâ means you have the condition now. âPâ means that you had the condition in the past, but not any more. If you have never had a condition, leave it blank.

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 motherâs side versus fatherâs side.

Problem List:

Please list ANY or ALL medical conditions you have EVER been diagnosed with, starting from birth on?