Forms | Nutraherbusa

PATIENT INTAKE FORM

Date of Birth

Paitient Information

Full name

Gender

Male

Female

Address

Marital Status

Single

Married

City / State

Phone

Email

Country

Zip code

Date of birth

MEDICAL HISTORY

Please identify the condition(s) that brought you to this office: required

On a scale of 1 to 10, with 10 being the worst pain and zero being no pain, rate your above complaints:

When did you start experiencing this problem?

Are you smoking?

Yes

No

Are you currently taking any medications?

Yes

No

Do you exercise daily?

Yes

No

Do you have any known allergies?

Yes

No

SURGICAL HISTORY

Have you ever had any surgical procedures on foot/ankle or anywhere else on your body?

Yes

No

If yes, please describe

Do you have any artificial joints?

Yes

No

If yes, where?

Do you have an artificial heart value?

Yes

No

SOCIAL HISTORY

Do you smoke?

Yes

No

Do you drink alcohol?

Yes everyday (5-7 days a week)

Yes, ocaasionally/socially

No/rarely

Substance abuse

What is your occupation

Do you exersice regulary?

Yes I do the following exercise

No I do not exercise regulary

FAMILY HISTORY

Is there any family history (blood relative) of (please indicate family member)

Thyroid/Hormone problem

Breathing or Lung Problem

Kidney Disease

Neurological Problem

REVIEW OF SYSTEMS

Please check the box if you currently have any of these symptoms

Cardiovascular

Fainting

Palpitation

Vascular disease

Valve problems

Genitourinary

Kidney disease

Kidney stones

Integumentary

Hematologic

Neurological

Muscoluskeletal

Joint pain

Joint instability

Arthritis

Respiratory

Name

Race

Date of birth

I prefer not to answer

I don't know

White, American Indian, Asian, Black or African, Native Hawaiian, Hispanic, etc

Current medication

none

I take these prescription or over the counter medications

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

No known allergies

Penicillin

Shellfish

Sulfa

Tape

Latex

Betadine

Aspirin

Tylenol

Ibuprofen

Codeine

Other

PATIENT HEALTH QUESTIONNAIRE

Please check if any of the following apply to you. Knowledge of these conditions may influence the type of treatment you receive.

Medications or supplements you currently take

HAVE YOU EVER:

ADDRESSING THE ISSUE THAT BROUGHT YOU TO OUR OFFICE

What is your major symptom/problem?

When did your symptoms begin?

Have you had this problem before?

Is the problem there

Constant

Comes & goes

With use

At rest?

Is the problem getting

Worse

No change

Better?

What makes it worse?

What makes it better?

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FEMALE QUESTIONS

Are you Pregnant, breastfeeding or nursing?

Yes

No

Surgical History C-Section

Yes

No

Remove uterus (hysterectomy)

Yes

No

0 to 10 years

11 to 22 years

23 to 45 years

70+

How do you born? (Normal / Operated)

Teething (Normal / Pointed)

Limbs development

walking started on age

pain in stomach

pain in stomach diarrhea and dysentery

menses started on age

Menses period: >>Heavy >> Normal >> Absent >> Delay

menses clothed watery dropping

piles/fissure >during menses >always >for some days

Leucorrhoea >watery >like eggs >like cruds >yellowish >smelling

acne on face on shoulder during menses

child miscarriages dreams habits fear of

pain in knee >pain in muscles >backache > during menses > during standing > during rest

Nails

Diabetes Normal / high A1C

By mention if your parent are having this diseases. (mother-father-sister-brother grandparents)

hearing vision

catarrh urine cramps foot soft burning sensation habit

Blood pressure / Thyroid Hypo/hyper

crying in alone religious mania complexion changes

numbness always sleeping holding for few second-legs during-traveling

Hair ful combing shampoo from eye lids

Constipation desire but>not able to pass>no desire >very hard

MALE QUESTIONS

0 to 10 YR

Teething age: food intake:

constipation diarrhea/dysentery

11 to 22

Teething age: food intake:

pimples

23 to 55

55+

dreams

like to eat : sweat salty sour bakery items

runing

choice of work : drawing music outdoor games mechanical games

studies: like Math like Science

PATIENT INTAKE FORM

MEDICAL HISTORY

Please identify the condition(s) that brought you to this office: required

On a scale of 1 to 10, with 10 being the worst pain and zero being no pain, rate your above complaints:

SURGICAL HISTORY

SOCIAL HISTORY

FAMILY HISTORY

Is there any family history (blood relative) of (please indicate family member)

REVIEW OF SYSTEMS

Please check the box if you currently have any of these symptoms

Cardiovascular

Genitourinary

Integumentary

Hematologic

Neurological

Muscoluskeletal

Respiratory

White, American Indian, Asian, Black or African, Native Hawaiian, Hispanic, etc

Current medication

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

Name:

Dose:

No known allergies

Penicillin

Shellfish

Sulfa

Tape

Latex

Betadine

Aspirin

Tylenol

Ibuprofen

Codeine

Other

PATIENT HEALTH QUESTIONNAIRE

Please check if any of the following apply to you. Knowledge of these conditions may influence the type of treatment you receive.

HAVE YOU EVER:

Have an accident (car, fall, sport, other)?

Had an operation?

Had an fracture?

Been hospitalized?

ADDRESSING THE ISSUE THAT BROUGHT YOU TO OUR OFFICE

Is the problem there

Is the problem getting

How doest it feel?

FEMALE QUESTIONS

Are you Pregnant, breastfeeding or nursing?

Surgical History C-Section

Remove uterus (hysterectomy)

0 to 10 years

11 to 22 years

23 to 45 years

23 to 45 years

70+

MALE QUESTIONS

0 to 10 YR

11 to 22

23 to 55

55+