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NATUROPATHIC MEDICINE PATIENT INTAKE FORM

Welcome to Divine Care Health Clinic. Your health questionnaire provides valuable information about your well being & underplaying causes of your health concerns. Please fill out this form prior to your consultation with Shanie Ruprai- ND.

GENERAL CONTACT INFORMATION

Name

Birth date

Address

Phone

Mobile

Email

Gender: Male Female (circle one)

Marital status: Single Married Divorced Defacto Widow

Occupation:

Medical Doctor:

Date of last physical exam:

Blood tests done? Y N

Emergency Contact

Name:

Relation to you:

Phone:

How did you find out about the clinic?

General Intake

What kind of conventional treatment have you received?

Have you ever seen a:

Current Medications (please list dosage)

1.

2.

3.

4.

5.

Nutritional Supplements (please list dosage)

1.

2.

3.

4.

5.

Are you currently working with a professional counselor, psychologist, social worker or therapist? Y N

Have you in the past? Y N

When?

Past Medical History: Which conditions do you have now (N) or in the past (P)

	N	P		N	P		N	P		N	P
Allergies			Weight problems			Stroke			STI/STD
Asthma			Gallstones			Cancer			HIV/AIDS
Eczema			Gout			Epilepsy			Reflux
Psoriasis			Arthritis			Migraine			Miscarriage
Ear infections			Thyroid problems			Pneumonia			Varicose veins
Strep throat			Anemia			Diabetes			High Cholesterol
Hay fever			High blood press			Malaria			Numbness/tingling
Measles			Rheumatic fever			Tuberculosis			Cold hands/feet
Mumps			Fainting			Small pox			Visual problems
Chicken pox			Poor memory			Polio			Warts
Whooping cough			Balance problems			Yeast infections			Mono
Eye infections			Speech problems			Gas/bloating			Depression
Scarlet fever			Ringing in ears			Hemorrhoids			Child abuse
Sinusitis			Jaundice			Parasites			Physical abuse
Canker sores			Hepatitis			Rectal bleeding			Sexual abuse
Acne			Heart disease			Herpes			Emotional abuse
Tonsillitis			Alcoholism			Headaches			Rape

Do you have any specific allergies? Y N

Please List:

Have you had any major injuries? Y N

If yes, please explain:

Have you had previous surgeries or hospitalizations? Y N

If yes, please explain: (include dates if known):

In your opinion, what is your weakest system (e.g. digestive, immune, cardiovascular, etc.)?

Family History: please indicate who, if anyone, is dealing with the following conditions in your family

	Mother	Father	Sister/Brother	Grandparents
Cancer
T.B
Heart Disease
Arthritis
Diabetes
High Blood Pressure
Asthma
Kidney Disease
Depression
Anemia
Alzheimer's
Parkinson's
Multiple Sclerosis
Lupus
Celiac Disease
Other

Vaccination

Have you been vaccinated? Y N

Any adverse reactions?

Which of the following do you currently use? (please list how much, how often)

Alcohol

Tobacco

Coffee

Hormones

Laxatives

Sedatives

Antacids

Cortisone

Recreational drugs (please specify)

What do you enjoy most in life?

What are your main interests and hobbies?

What do you worry most about in life?

What nurtures you?

Do you have a religious/spiritual practice?

Do you exercise? Y N If so, what do you do?

How would you rate the quality of your sleep?

Do you have troubles falling or staying asleep?

How many hours of sleep do you get per night?

How many do you feel you need?

Do you nap or rest during the day?

How would you describe your energy?

Are you sexually active? Y N

Are you experiencing a loss in sexual desire? Y N

Do you use birth control? Y N

If so, what form?

Digestion

How would you describe your digestion?

How frequently do you have a bowel movement?

Any history of: (tick out all that apply)

Gas

Bloating

Diarrhea

Constipation

Blood In Stool

Undigested Food

Black Stool

Strong Odor

Musculoskeletal

Do you have muscle aches and pains? Y N

If so, where?

Do you have joint aches and pains? Y N

If so, where?

Does this interfere with your daily activity? Y N

Is this due to an accident/injury? Y N

Environment

Is your home damp or moldy? Y N

Do you have specialized air filtration at home? Y N

Do you live/work in the city? Y N

Do you work in an office building? Y N

Do the windows open? Y N

Are you exposed to toxic materials? Y N

Do you smoke or are you exposed to second hand smoke? Y N

What do you use as drinking water?

Tap Bottled Filtered Reverse osmosis

Is there anything else you feel I should know?

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