test – Apple Naturopathic and Medical Aesthetics

Today's date:

Your name:*

First

Last

Date of Birth:

Phone:

Area Code

Phone Number

E-mail:

Are you familiar with naturopathic medicine?

How did you hear about our Clinic?

Main reason(s) for seeking Naturopathic medical care. Please indicate order of importance and when symptoms first appeared.

Medical Doctor's name:

Do you consult with other health care professionals? If so, please list:

Please list medication/drugs you are currently taking:

Please list all supplements you are currently taking:

Do you wear a medic alert bracelet?

yes

If so, for which condition?

Do you have a pacemaker?

yes

Do you have any medication/drug related allergies?

yes

If so, please list medication/drugs:

Do you have any food/environmental allergies or sensitivities?

yes

If so, please list food/environmental:

For Women: Date of last PAP test? (This screening is offered by Dr. Kneeland)

Age of first menstrual period?

If over 40, date of last mammogram?

Are there any conditions after which you have never been totally well since, or which have been more serious than usual?

Please list any operations, hospitalizations, childbirths, major accidents or traumas you have had:

1 Date:

2 Date:

3 Date:

4 Date:

5 Date:

6 Date:

Please indicate below which of the following conditions have affected your relatives: Indicate: F-Father, M=Mother, S1=Sibling, S2=Sibling etc., PGM=Paternal Grandmother, MGM=Maternal Grandmother, PGF=Paternal Grandfather, MGF=Maternal Grandfather, PA-Paternal Aunt, MA Maternal Aunt, PU=Paternal Uncle, MU=Maternal Uncle

If cancer is checked off above, please indicate type of cancer:

Have you lost any weight recently?

How many pounds?

What exercise do you do and how much?

What are your short-term health goals?

What are your long-term health goals?

Extra Notes:

Word Verification: