Oregon Natural Medicine: Medical History Form
Please complete this intake and submit before your first appointment. This best allows our doctors to serve you!
Full Name
*
Gender
Female
Male
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
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2012
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1926
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1924
1923
1922
1921
1920
Year
Age
E-mail
*
May we contact you by email?
Yes
No
Address
*
Home or Cell number
*
Marital Status
Single
Married/Partnered
Divorced
Widowed
Number of Children
Emergency Contact
Emergency Contact?
Contact Phone number
Employment
Your Employer?
Your Occupation?
Health Insurance Company?
Referrals
How did you hear about us?
*
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Current Medical Information
Current health concerns and reason for this appointment
*
Allergies to drugs, foods, environment
*
Medications you currently take(prescription drugs and over-the-counter)
*
Supplements you currently take(vitamins, herbal, homeopathic)
*
Past Medical Issues
Surgeries you have had
*
Major illnesses, injuries or car accidents you have had in the past
*
Female Only
Do you have a monthly period?
Yes
No, I am post-menopause
No, I have hormone imbalances
No, I have had a hysterectomy
Date of last menstrual period
Are you pregnant?
No
Yes
Unsure
Number of full term pregnancies
Number of Miscarriages
Number of Abortions
Are you currently sexually active?
Yes, only with men
Yes, only with women
Yes, with both men & women
No
What form of contraception (birth control) do you use?
None
Birth Control Pills, Patch or Nuva-Ring
IUD
Condoms, Spermicide, Diaphragm
Vasectomy or Tubes-Tied
Other
Review Of Systems: Women & Men
Please check if you have or had have any of the following: there is room at the end to list any other symptoms
General Health
*
No current general issues
Recent Weight Loss
Recent Weight Gain
Night Sweats
Fevers
Fatigue
History of Cancer
Autoimmune illness
Genetic Condition
Other, please type in box at end
Mood/Psych.
*
No current mood or psychiatric issues
Anxiety
Depression
Panic Attacks
Bi-polar
Schizophrenia
ADD/ADHD
Irritability
Weepy
Anger issues
Other (list in box near end)
Head, Eyes, Ears, Nose, Throat
*
None, no head,sinus, eye, ear, nose complaints
Migraines
Chronic Headaches
Dizziness/Vertigo
Fainting
Chronic Dry Eyes
Blurred Vision
Loss of smell
Bloody Nose
frequent sore throat
runny nose
Watery eyes
Sneezing
Difficulty Swallowing
Ear Infection/ache
Loss of Hearing
Cold sores/Herpes
Other (list in box near end)
Endocrine
*
No endocrine complaints
Hypothyroid
Hyperthyroid
Hashimoto's
Cushings Disease
Addison's Disease
PCOS
Diabetes-Type I
Diabetes-Type II
Metabolic Syndrome
Chilly all the time
Cold hands or feet
Hot and sweaty often
Other (list in box near end)
Heart & Lungs
*
No heart or lung complaints
Shortness of breath
Chest Pain
Heart Attack
Lung Disease
Heart Disease
Palpitations
Pneumonia
Bronchitis
High Blood Pressure
High Cholesterol
High Triglycerides
Other (list in box near end)
Digestive/Liver
*
No digestive complaints
Irritable Bowel Syndrome
Crohn's Disease
Ulcerative Colitis
stomach ulcer
Gallbladder Attacks
Pancreatitis
Heartburn/ GERD
hemorroids
constipation
diarrhea
blood in the stool
excessive gas
Hepatitis
Cirrhosis
Other (list in box near end)
Number of Bowel Movements daily
*
Please Select
Less than 1 per day
1-2 daily
2-3 daily
3-4 daily
5 + daily
Urinary
*
NO urinary complaints
Bladder Infection
Kidney Stones
Interstitial Cystitis
Incontinence
Kidney Infection
waking at night to urinate
blood in urine
Other (list near end)
Female: Gyn & Breast
No female complaints
Hysterectomy
PMS
Endometriosis
Infertility
Breast tenderness before periods
Breast cancer
Fibroadenoma-benign breast tumor
Fibrocystic Breasts
Yeast Infections
BV: bacterial vaginosis
Fibroids
Heavy periods
Irregular periods
Genital Herpes
Abnormal Pap
low libido
Vaginal dryness
pain with intercourse
Ovarian Cyst/tumors
Male health
No male complaints
Erectile dysfuntion
Genital herpes
BPH
Prostatitis
low libido
Genital Warts
other sexually transmitted infection
Skin
*
No skin complaints
acne
rashes
eczema
psoriasis
hives
Varicose veins
Spider veins
dry skin
skin cancer
Other (list in box near end)
Musculo-skeletal
*
No muscle/bone complaints
broken bones
chronic aches
Fibromyalgia
sciatica
nerve pain/neuropathy
low back pain
neck pain
shoulder pain
arm pain
leg pain
foot/ankle pain
hand/wrist pain
Carpal tunnel syndrome
Other (list in box below)
List any other condition, illness or symptoms you have(not listed above)
History of Abuse
*
None
Verbal
Physical
Sexual
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Constitutional
Temperature, you run..
Cold
Warm
Normal
Favorite Foods
Foods you hate
Fears
Energy is BEST at:
morning(6-11am)
mid-day(12-4pm
evening(5-9pm)
night (after 10pm)
Company, you prefer
to be alone often
mix of alone & company
love having people around
You would best describe yourself as..
Family Health
Mother's health
*
Please Select
Alive, in good health
Alive, health is ailing
Deceased
Conditions that run on your mothers side of family:
Cancer-breast
Cancer-other
High Blood Pressure
High Cholesterol
Diabetes
Thyroid conditions
Bleeding disorders
Heart Attack
Osteoporosis
Father's Health
*
Please Select
Alive, in good health
Alive, health is ailing
Deceased
Conditions that run on your Father's side of family
Cancer-breast
Cancer-other
High Blood Pressure
High Cholesterol
Diabetes
Thyroid conditions
Bleeding disorders
Heart Attack
Osteoporosis
Social Health
Describe a typical breakfast, lunch & dinner
*
Special Diet
Please Select
Vegetarian
Vegan
Gluten-Free
Dairy-Free
other
History of Eating Disorder
Please Select
No
Yes, Anorexia
Yes, Bulemia
Yes, Compulsive Over-eating
Number of alcoholic drinks per week?
*
Please Select
zero
1-4
5-10
11 +
Have you ever used tobacco products?
*
No, never
I currently do
No, but I have in the past
Drug Use: past or present
Marijuana
Cocaine or Heroin
Methamphetamines
Other
Describe your current exercise routine
*
Your hobbies?
You may print this form and bring to your appointment; or press submit so that your doctor may review it before your appointment (prefered)
Submit
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