Natural Rhythm | Natural Medicine Washington DC

CONFIDENTIAL PATIENT INFORMATION

PLEASE NOTE: Naturopathic medicine treats the whole person, not just diseases. The more accurate and complete the information you provide, the better we can serve you and help with your total health. As with all medical information, your answers are confidential and cannot be released without your written consent.

Patient’s Full Name Sex

Home Address Phone

City State Zip Code

Age DOB Place of Birth

Employer Occupation

Business Phone E-mail Address

Significant Relationship Status:

Single Married Non-married Partner Widowed Separated Divorced

Current Living Arrangement: I live with:

Spouse/Family Partner Alone Roommates Children

Other

PERSON TO CONTACT IN CASE OF EMERGENCY Relationship Phone Address HOW DID YOU HEAR ABOUT US? I understand and agree that I am financially responsible for all charges and that payment must be made at the time of the visit unless other arrangements have been made in advance. I understand and agree that I will pay the full fee for the doctor’s time if I cancel or reschedule my appointment with less than 24 hours notice.

CURRENT HEALTH CONCERNS: MEDICATIONS and SUPPLEMENTS: Please include prescription, non-prescription, vatamins, and other supplements. List the dosage(how much you take & how often?) ALLERGIES: List allergies to drugs, foods, and environmental (i.e. dust, pollen, chemicals) HOSPITALIZATIONS, DENTAL WORK, SURGERIES, ACCIDENTS, INJURIES: MEDICAL TREATMENT: List other physicians who are treating you

Last complete physical Last blood test

VACCINATIONS: CHILDHOOD ILLNESSES:

FOOD and DIET:

24 HOUR DIET RECALL
Please list everything you ate yesterday

BREAKFAST

LUNCH

DINNER

SNACKS

Daily Water Intake

SLEEP HABITS:

What time do you go to bed? Wake up? Wake rested?

Wake in middle of night? Why?

EXERCISE:

Do you exercise regularly? How often?

Describe exercise

LIFESTYLE FACTORS:

Caffeine Alcohol Recreational Drugs Tobacco

How Much? How Often

Have you ever smoked? How long? Quit date?

FAMILY HISTORY: List any blood relatives affected by:

Please answer the questions below as appropriate
Circle “0” for conditions that DO NOT apply to you
Circle 1 for mild/rarely ~ 2 for moderate ~ 3 for severe/frequent ~ P for past

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