Form | Restore To Health Naturopathica Clinic

Patient Data

Name *

First

Last

Phone

Email *

Mailing address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Birth Date

Social Security#

Number of children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Current Complaints

Nature of Injury

Automobile
Work
Other

Please describe

Date of Injury

Date symptoms appeared

Have you ever had same condition?

List of other practitioners seen for this injury/condition

Have you ever been under chiropractic care?

Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

* If an auto accident, please provide:

Insurance Company Name

Contact Person

Phone

Claim

Medical History

Have you been treated for any conditions in the last year?

Date of last physical exam

Is there a chance that you are pregnant?

Have you had X-rays taken?

What medications are you taking and for what conditions (Please list dosage and amounts, etc)l

What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency).

Have you ever:

Broken bones?

Been hospitalized?

Been in an auto accident?

Had Sprains/Strains?

Been struck unconscious?

Had surgery?

Family History

Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Other Medical Conditions

Do you experience pain every day?

Do your symptoms interfere with daily life?

Does pain wake you up at night?

Are your symptoms worse during certain times of the day?

Do changes in weather affect your symptoms?

Do you wear orthotics?

Do you take vitamin supplements?

What activities aggravate your symptoms?

Habits

Alcohol

None
Light
Moderate
Heavy

Coffee

None
Light
Moderate
Heavy

Tobacco

None
Light
Moderate
Heavy

Drugs

None
Light
Moderate
Heavy

Exercise

None
Light
Moderate
Heavy

Sleep

None
Light
Moderate
Heavy

Appetite

None
Light
Moderate
Heavy

Soft Drinks

None
Light
Moderate
Heavy

Water

None
Light
Moderate
Heavy

Salty Foods

None
Light
Moderate
Heavy

Sugary Foods

None
Light
Moderate
Heavy

Artificial Sweeteners

None
Light
Moderate
Heavy

EMOTIONAL HEALTH

Have you ever been involved in psychotherapy or counseling?

Duration of time?

With whom?

Was this work a positive experience?

In what way?

If you have previously worked with a counselor, do you feel it would be helpful now?

HOBBIES

List things you enjoy doing. What do you nd rewarding about these activities?

EXERCISE

Do you exercise?

VOCATION

Do you enjoy your occupation?

Does it provide fulfilment?

Describe your work environment

Are you content with your current level of income?

Are you exposed to any hazardous materials?

How would you envision a perfect job for yourself?

REFERRAL

Referring physician or where you found out about us

Referring Physician

Phone

PREVIOUS MEDICAL TREATMENTS

Please list below other practitioners you have worked with in the past (including physicians, chiropractic, acupuncturist, counselors, psychiatrist, energy workers or others)

(Name, Type of Therapy, For What, When Treated, Helpful?)

PREVIOUS MEDICAL HISTORY

(Diagnosis, Problem Started, How Diagnosed, Treatment, Result)

OB/GYN

Pregnancies (how many)

Any complications?

What was the date of your last pelvic exam/pap test?

Was it normal?

Do you perform self-breast exam?

HOSPITALIZATIONS AND SURGICAL PROCEDURES

Please list past hospitalizations and any previous medical procedures or surgeries such as tonsillectomy, appendectomy or wisdom tooth extraction etc.

(Surgery or Procedure, Date, Reason, Result/Scars)

Additional comments on previous medical experience

FAMILY MEDICAL HISTORY

(Grandmother, Grandfather, Mother, Father, Brothers/Sisters, Other)

TOBACCO/ALCOHOL

PREVIOUS MEDICATIONS

Please list medications which you have tried in the past, why you took them and for how long, positive or negative effects, and who prescribed them.

(Medicine/Dose, Why, How Long, Effects, Prescribed By)

PREVIOUS SUPPLEMENTS

Please list supplements which you have tried in the past, why you took them and for how long, positive or negative effects, and who prescribed them.

(Supplements/Dose, Why, How Long, Effects, Prescribed By)

SLEEP PATTERNS

Do you have normal, restful sleep?

Do you feel the need to nap?

Do you have trouble getting to sleep?

Do you snore?

Do you wake up frequently?

Are there preparations you have taken to help with sleep?

DIET

What are typical foods you would choose for the following?

(Breakfast, Lunch, Dinner, Snacks)

How much of the following do you consume each day or week?

SLICES OF WHITE BREAD, ROLLS OR BAGELS

Daily/ Weekly

CUPS OF CAFFEINATED COFFEE

Daily/ Weekly

CUPS OF CAFFEINATED TEA

Daily/ Weekly

DIET SODAS

Daily/ Weekly

SODA POP CONTAINING CAFFEINE

Daily/ Weekly

SODA POP WITHOUT CAFFEINE

Daily/ Weekly

POTATO CHIPS OR SIMILAR SNACK FOODS

Daily/ Weekly

CANDY

Daily/ Weekly

CHOCOLATE

Daily/ Weekly

CHEESE

Daily/ Weekly

SALTY FOODS

Daily/ Weekly

ICE CREAM

Daily/ Weekly

DOUGHNUTS

Daily/ Weekly

CURRENT MEDICAL TREATMENT

Please list practitioners you consider to be part of your current healthcare team:

Name / Phone / Specialty / Condition(s) treated / Helpful?

CURRENT MEDICATIONS

Please list only the medications you are currently using, why you took them and for how long, positive or negative effects, and who prescribed them.

(Medication/Dose, Why, How Long, Effects, Prescribed By)

CURRENT SUPPLEMENTS

Please list only the supplements you are currently using, why you took them and for how long, positive or negative effects, and who prescribed them.

(Supplement/Dose, Why, How Long, Effects, Prescribed By)

ALLERGIES

Please list any medication, food, or environmental allergy. Use the last page of booklet if additional space is needed.

(Allergy, Type of Reaction)

SYMPTOM

GENERAL

Cold hands and feet

PAST
PRESENT

cold intolerance

PAST
PRESENT

Fushing

PAST
PRESENT

Heat intolerance

PAST
PRESENT

fever

PAST
PRESENT

fatigue

PAST
PRESENT

malaise

PAST
PRESENT

dif culty falling asleep

PAST
PRESENT

night waking

PAST
PRESENT

nightmares

PAST
PRESENT

no dream recall

PAST
PRESENT

early waking

PAST
PRESENT

daytime sleepiness

PAST
PRESENT

headache

PAST
PRESENT

migraine

PAST
PRESENT

EYES

itching

PAST
PRESENT

blurred vision

PAST
PRESENT

“floaters”

PAST
PRESENT

glaucoma

PAST
PRESENT

see halos

PAST
PRESENT

watering

PAST
PRESENT

pain

PAST
PRESENT

dark circles

PAST
PRESENT

cataracts

PAST
PRESENT

double vision

PAST
PRESENT

EARS

hearing loss

PAST
PRESENT

frequent infections

PAST
PRESENT

pain

PAST
PRESENT

dizziness

PAST
PRESENT

ringing

PAST
PRESENT

EATING

can’t lose weight

PAST
PRESENT

can’t gain weight

PAST
PRESENT

poor appetite

PAST
PRESENT

carbohydrate craving

PAST
PRESENT

carbohydrate intolerance

PAST
PRESENT

binging

PAST
PRESENT

bulimia/anorexia

PAST
PRESENT

salt craving

PAST
PRESENT

alcohol craving

PAST
PRESENT

bread craving

PAST
PRESENT

chocolate craving

PAST
PRESENT

diet soda craving

PAST
PRESENT

need coffee

PAST
PRESENT

smoke tobacco

PAST
PRESENT

used cocaine

PAST
PRESENT

used marijuana

PAST
PRESENT

used other drugs

PAST
PRESENT

MUSCULAR

calf cramps

PAST
PRESENT

foot cramps

PAST
PRESENT

tmj problems

PAST
PRESENT

muscle twitches: around eyes

PAST
PRESENT

muscle twitches: arms or legs

PAST
PRESENT

muscle spasms

PAST
PRESENT

chest tightness

PAST
PRESENT

tendonitis

PAST
PRESENT

muscle weakness

PAST
PRESENT

muscle stiffness

PAST
PRESENT

joint swelling

PAST
PRESENT

joint pain

PAST
PRESENT

joint stiffness

PAST
PRESENT

joint redness

PAST
PRESENT

MOOD/NERVES

anxiety

PAST
PRESENT

irritability

PAST
PRESENT

depression

PAST
PRESENT

panic attacks

PAST
PRESENT

agoraphobia

PAST
PRESENT

phobias

PAST
PRESENT

fearfulness

PAST
PRESENT

paranoia

PAST
PRESENT

suicidal thoughts

PAST
PRESENT

dizzy (spins)

PAST
PRESENT

fainting

PAST
PRESENT

seizures

PAST
PRESENT

difficulty: concentrating

PAST
PRESENT

difficulty: with balance

PAST
PRESENT

difficulty: with thinking

PAST
PRESENT

difficulty: with judgment

PAST
PRESENT

difficulty: with speech

PAST
PRESENT

difficulty: with memory

PAST
PRESENT

numbness

PAST
PRESENT

tingling

PAST
PRESENT

DIGESTION

upper abdomen pain

PAST
PRESENT

lower abdomen pain

PAST
PRESENT

bloating of whole abdomen

PAST
PRESENT

burping

PAST
PRESENT

flatus/gas

PAST
PRESENT

diarrhea

PAST
PRESENT

undigested food in stools

PAST
PRESENT

mucous in stools

PAST
PRESENT

blood in stools

PAST
PRESENT

hemorrhoids

PAST
PRESENT

anal spasms

PAST
PRESENT

Fissures

PAST
PRESENT

strong stool odor

PAST
PRESENT

constipation

PAST
PRESENT

difficulty swallowing

PAST
PRESENT

dentures with poor chewing

PAST
PRESENT

bad teeth

PAST
PRESENT

gums bleed

PAST
PRESENT

periodontal disease

PAST
PRESENT

dry mouth

PAST
PRESENT

sore tongue

PAST
PRESENT

canker sores

PAST
PRESENT

fever blisters

PAST
PRESENT

cracking at corner of lips

PAST
PRESENT

intolerance of lactose

PAST
PRESENT

intolerance of all dairy

PAST
PRESENT

intolerance of gluten-wheat

PAST
PRESENT

intolerance of fatty foods

PAST
PRESENT

intolerance of corn

PAST
PRESENT

intolerance of yeast

PAST
PRESENT

intolerance of eggs

PAST
PRESENT

heartburn

PAST
PRESENT

nausea

PAST
PRESENT

vomiting

PAST
PRESENT

SKIN

psoriasis

PAST
PRESENT

eczema

PAST
PRESENT

hives

PAST
PRESENT

rash

PAST
PRESENT

athletes foot

PAST
PRESENT

jock itch

PAST
PRESENT

acne

PAST
PRESENT

easy bruising

PAST
PRESENT

dark circles under eyes

PAST
PRESENT

itching

PAST
PRESENT

thick callouses

PAST
PRESENT

oily skin

PAST
PRESENT

dandruff

PAST
PRESENT

dry skin

PAST
PRESENT

ears get red

PAST
PRESENT

strong body odor

PAST
PRESENT

herpes - genital

PAST
PRESENT

shingles

PAST
PRESENT

skin cancer

PAST
PRESENT

vitilego

PAST
PRESENT

NAILS

soft

PAST
PRESENT

fungus on ngers

PAST
PRESENT

brittle

PAST
PRESENT

white spots

PAST
PRESENT

fungus on toes

PAST
PRESENT

RESPIRATORY

loss sense of smell

PAST
PRESENT

loss sense of taste

PAST
PRESENT

nasal stuf ness

PAST
PRESENT

sinus fullness

PAST
PRESENT

sinus infection

PAST
PRESENT

post nasal drip

PAST
PRESENT

bad odor in nose

PAST
PRESENT

bad breath

PAST
PRESENT

nose bleeds

PAST
PRESENT

hay fever - spring

PAST
PRESENT

hay fever - summer

PAST
PRESENT

hay fever - fall

PAST
PRESENT

hay fever - seasonal

PAST
PRESENT

winter stuf ness

PAST
PRESENT

sore throat

PAST
PRESENT

hoarseness

PAST
PRESENT

shortness of breath

PAST
PRESENT

cough - dry

PAST
PRESENT

cough - productive

PAST
PRESENT

wheezing

PAST
PRESENT

odor sensitive

PAST
PRESENT

URINARY

urgency

PAST
PRESENT

leaking

PAST
PRESENT

pain

PAST
PRESENT

hesitancy

PAST
PRESENT

kidney stone

PAST
PRESENT

infection

PAST
PRESENT

bleeding

PAST
PRESENT

incontinence

PAST
PRESENT

MALE

prostate infection

PAST
PRESENT

prostate enlargement

PAST
PRESENT

infertility

PAST
PRESENT

impotence

PAST
PRESENT

ejaculation problem

PAST
PRESENT

genital pain

PAST
PRESENT

poor libido

PAST
PRESENT

testicular lumps

PAST
PRESENT

FEMALE REPRODUCTIVE

vaginal discharge

PAST
PRESENT

vaginal odor

PAST
PRESENT

vaginal itch

PAST
PRESENT

poor libido

PAST
PRESENT

breast lumps

PAST
PRESENT

breast cysts

PAST
PRESENT

premenstrual: bloating - face

PAST
PRESENT

premenstrual: bloating - abdomen

PAST
PRESENT

premenstrual: puffy hands

PAST
PRESENT

premenstrual: puffy feet

PAST
PRESENT

premenstrual: breast tenderness

PAST
PRESENT

premenstrual: irritability

PAST
PRESENT

diarrhea

PAST
PRESENT

constipation

PAST
PRESENT

decreased sleep

PAST
PRESENT

chocolate craving

PAST
PRESENT

carbohydrate craving

PAST
PRESENT

food craving

PAST
PRESENT

Age at first period

Did you ever use birth control pills?

Enter date ranges

Did taking the pill agree with you?

Are you taking the pill now?

Contraception use now?

Date of last pap smear

Age at last (final) period

PREGNANCIES: (INDICATE NUMBER)

Miscarriages

Abortions

Preemies

Term births

Toxemia

Nausea/vomiting

Mid
moderate
severe

ENVIRONMENTAL QUESTIONS

Have you ever or do you use any of the following at/near home or work?

spring water

Home
Work

well water

Home
Work

water purifler

Home
Work

damp cellar

Home
Work

wooded area

Home
Work

power lines

Home
Work

smoke stacks

Home
Work

dump

Home
Work

gas stove

Home
Work

gas furnace

Home
Work

gas hot water heater

Home
Work

gas dryer

Home
Work

wood stove

Home
Work

coal stove

Home
Work

kerosene space heater

Home
Work

forced hot air heat

Home
Work

electric blankets

Home
Work

feather pillows

Home
Work

foam rubber pillows

Home
Work

feather/down: comforter

Home
Work

feather/down: coat/jacket

Home
Work

hair dyes

Home
Work

exterminator

Home
Work

stuffed upholstery

Home
Work

moth balls

Home
Work

animals

Home
Work

mold on: shower curtain

Home
Work

mold on: basement walls

Home
Work

mold on: first story walls

Home
Work

mold on: second story walls

Home
Work

garage under living space

Home
Work

urea formaldehyde insulation

Home
Work

garden chemicals

Home
Work

Website

Patient Data

Mailing address

Current Complaints

Insurance Information

Medical History

Have you ever:

Family History

Other Medical Conditions

Habits

EMOTIONAL HEALTH

HOBBIES

EXERCISE

VOCATION

REFERRAL

PREVIOUS MEDICAL TREATMENTS

OB/GYN

HOSPITALIZATIONS AND SURGICAL PROCEDURES

TOBACCO/ALCOHOL

PREVIOUS MEDICATIONS

PREVIOUS SUPPLEMENTS

SLEEP PATTERNS

DIET

How much of the following do you consume each day or week?

CURRENT MEDICAL TREATMENT

CURRENT MEDICATIONS

CURRENT SUPPLEMENTS

ALLERGIES

SYMPTOM

GENERAL

EYES

EARS

EATING

MUSCULAR

MOOD/NERVES

DIGESTION

SKIN

NAILS

RESPIRATORY

URINARY

MALE

FEMALE REPRODUCTIVE

PREGNANCIES: (INDICATE NUMBER)

ENVIRONMENTAL QUESTIONS

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