Download Initial Intake Form- Naturopathy

The Body Shop
Informed Consent and Request for Naturopathic Medicine
I understand that the evaluation, diagnosis and treatment by a naturopathic physician, and specifically by
Dr. Winter at The Body Shop may include, but is not limited to:
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Interview (history taking)
Physical examination
Common diagnostic procedures (such as, diagnostic imaging, laboratory evaluation of blood, urine,
stool, and saliva, Pap smears)
Dietary advice and therapeutic nutrition (such as therapeutic use of foods, diet plans, nutritional
supplements, intravenous and intramuscular injections)
Acupuncture
Prolotherapy and/or PRP Therapy
Botanical Medicine and nutraceuticals/supplements
Homeopathic remedies
Over the Counter medications
Prescription Medications to be filled at a pharmacy
I understand and informed that in the practice of Naturopathic Medicine there are risks and benefits with
evaluation, diagnosis and treatment including but not limited to the following:
Potential risks: pain, discomfort, minor bruising from acupuncture, IV, or prolotherapy, allergic reaction to
prescribing herbs, supplements, prescription medications; an aggravation of pre-existing symptoms.
Potential benefits: restoration of the body’s maximal functioning capacity, relief of pain and symptoms of
disease, assistance in injury and disease recovery and prevention of disease or its progression.
Notice to all pregnant women: all female patients must alert the provider if they know or suspect that they
are pregnant, since some of the therapies could present a risk to the pregnancy.
By signing below. I (print name), _________________________acknowledge that I have been provided
ample opportunity to read this form or that it has been read to me. I also understand that it is my
responsibility to request that the provider explain therapies and procedures to my satisfaction. I further
acknowledge that no guarantees have been given to me concerning the results intended from the
treatment. I intend that this consent form is to cover the entire course of treatments for my present
condition and any future conditions for which I am seeking.
________________________________________
Signature
______________________
Date
_______________________________________
Signature of Patient Representative or Guardian
515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 
The Body Shop
PATIENT INFORMATION FORM:
Name:______________________________Date of birth:_____________Age:______________
Address:______________________________________________________________________
Phone: (home) _________________________(mobile)_________________________________
E-mail address:_________________________________________________________________
Occupation:___________________________Name of employer:_________________________
Name of Spouse:________________________________________________________________
Emergency Contact Person:_______________________________________________________
Emergency Contact Phone:_______________________________________________________
Relationships:__________________________________________________________________
I authorize employees of The Body Shop to leave a detailed message for me on a voice message
device associated with the phone number listed below, regarding my:
1. Laboratory reports:
2. Protected health information:
___ yes (initials______) ___no (initials_____)
___ yes (initials_____) ___no (initials_____)
If you answered YES to either of the above on which phone number is it acceptable to leave
this information?_________________________
If you answered NO to either of the above, the physicians and/or staff members at The Body
Shop will, as necessary, leave a message indicating your need to call the clinic to retrieve any of
your health-related information.
Whom may we thank for referring you? ___________________________________
515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 
The Body Shop
Dr. Erin Winter NMD
New Patient Intake Form
Date:
Patient Name:
DOB:
Age:_________________
List in Order of importance what your problems are:
1)
2)
3)
4)
5)
Last time you had blood work done and with what physician:
Family History
Check YES, NO, or ? (don’t know) for blood relatives
Yes
No
?
Alcoholism
Allergies
Anemia
Asthma
Auto-immune disease
Cancer
Diabetes
Gout
Who in the family: Yes
No
?
Who in the family:
Heart Disease
Hypoglycemia
High Blood Pressure
Mental Illness
Skin Disorders
Seizure of Epilepsy
Stroke
Thyroid Disorders
Glaucoma
Osteoporosis
List All Surgeries & Hospitalizations, including date occurred:
1)
2)
3)
4)
5)
6)
Please Note When & Why You Have Had Each of the Following:
X-Rays:
Ultrasounds:
TB Test:
HIV:
Last Eye Exam:
MRI/Cat Scans:
Accidents:
HCV:
Last Dental Visit:
Did you have the following Disease (D), Get Immunized (I), or Neither (N):
Measles:
D I N
Tetanus:
D I N
German Measles: D I N
Chicken Pox:
D I N
Whooping Cough:
D I N
Any vaccination reactions:
Mumps:
Hemophilus (Hib):
D I N
D I N
Rubella:
Hepatits B:
List Yes (Y), No (N) or Past (P) regarding use of the following:
Antacids: Y N P
Analgesics: Y N P
Soda Pop: Y N P
Alcohol: Y N P
Any Alcohol Addiction:
Recreational Drugs:
Any Drug Treatment:
Steroids: Y N P
Smoking: Y N P
Packs per day & number of years:
Laxatives: Y N P
Coffee:
Y N P
Cups per day if Yes/Past:
Ounces per day if Yes/Past:
How often & how much if Yes/Past:
Y N P
Any Alcohol Treatment: Y N P
Y N P
Any Drug Addictions:
Y N P
Y N P
List All Allergies to Medications or Foods:
515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 
D I N
D I N
Review of Systems:
Present Weight:
Weight one year ago:
Maximum weight and when:
Minimum weight as adult & when:
Ideal Weight:
Good Energy: Yes No Past
Fatigue:
Yes No Past
If you have fatigue, when is it the worst?
Morning
Afternoon
Evening
If you have fatigue, can you do what you need to during the day?
Yes
No
Height:
REGARDING THE NEXT LONG SECTION: Please check any of the symptoms you’ve had in the past or have now, and explain next to it.
Skin
□ Rash
□ Hives
□ Psoriasis/Eczema
□ Dry skin
□ Cancer
□ Color change
□ Lump
□ Itchy
□Warts/moles
□ Perspiration
Respiratory
□ Asthma
□ Bronchitis
□ Cough
□ Pneumonia
□ Painful Breathing
□ TB
□ Shortness of Breath with Exertion
□ Shortness of Breath sitting
□ Shortness of Breath lying down
□ Wheezing
Head
□ Headache □ Migraines
□ Head Injury
□ Dandruff
□ Oil/dry hair
□ Hair loss
Cardiovascular
□ Arrhythmias
□ Chest Pain
□ Edema
□ High Blood Pressure
□ Low Blood Pressure
□ Palpitations
□ Murmurs
□ Rheumatic Fever
Nose
□ Frequent colds
□ Congestion
□ Polyps
□ Nosebleeds
□ Post Nasal Drip
□ Seasonal Allergies
Eyes
□ Dry/watery
□ Double Vision
□ Blurry Vision
□ Cataracts
□ Glaucoma
□ Strain
□ Itchy
□ Styes
□ Discharge
□ Dark under eyelid
Mouth and Throat
□ Sore Throat
□ Canker Sores
□ Cold Sores (fever blisters)
□ Gum Disease
□ Loss of Taste
□ Cavities
□ Hoarseness
□ Dentures
Neck
□ Stiffness
□ Full movement
□ Swollen Glands
□ Tension
Urinary Tract
□ Discharge/blood
□ Frequent Infections
□ Kidney Stones
□ Incontinence
□ Pain with Urination
□ Urgency
Gastrointestinal
Bowel Movement Frequency: ___ / day
□ Bloating
□ Constipation/Diarrhea
□ Nausea/ Vomiting
□ Change in appetite
□ Recent Bowel Changes
□ Heartburn
□ Indigestion
□ Hemorrhoids
□ Ulcers
□ Pancreatitis
□ Gall Bladder Disease
□ Liver Disease
□ Other: _____________________
Nervous
□ Carpal Tunnel Syndrome □ Paralysis
□ Sciatica
□ Tingling/ Numbness
□ Seizures
□ Fainting
Mental/ Emotional
□ Anxiety
□ Anger/ Irritability
□ Depression
□ Eating Disorder
□ Fear/ Panic
□ High Strung/ Tense
□ Psych hospitalization
□ Suicidal
Endocrine
□ Diabetes
□ Fatigue
□ Thyroid
□ Other: ______________________
Male Genitalia
Sexual Orientation: Hetero Homo Bi
Sexually Active: Yes No
□ Hernia
□ Discharge
□ Impotency
□ Prostate Disease/ Symptoms: _______
□ Testicular Pain/ Swelling
□ STD: ____________
Female Genitalia
Sexual Orientation: Hetero Homo Bi
Sexually Active: Yes No
Age Period began: _____
Period lasts _____ days
How often periods occur: every ____ days
□ Heavy Menstrual Bleeding
□ Menstrual Pain
□ Menstrual Cramping
□ PMS
□ Food Cravings
Number of pregnancies: _____
Number of live births: ____
Number of abortions: ____
Number of miscarriages: ___
Date of last Pap Smear: ________ Normal Abnormal
□ Dry Vagina
□ Pain with intercourse
□ STD: ___________
□ Healthy Libido
□ Vaginitis
Age at Menopause: ____
□ Use of Hormones:________________________
□ Use of Birth Control: ______________________
Musculoskeletal
□ Weakness
□ Stiffness
□ Arthritis
□ Leg Cramps
□ Tremors
□ Pain
515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 
How often do you exercise?
For how long?
How long per night?
Nightmares: Y N P
Sleep walk: Y N P
What type of exercise?
Hobbies:
Sleep
If you wake up frequently, what is the reason?
Wake Refreshed: Y N P
Must nap during the day: Y N P
Grind teeth:
Y N P
Snore:
Y N P
Toxin Exposure
Did you grow up near any refinery, polluted area or in a home with leaded paint? If so, what sort of pollution were you exposed
to?
Have you had any jobs where you were exposed to solvents, heavy metals, fumes or other toxic materials?
Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other
refurbishing?
Are you particularly sensitive to perfumes, gasoline or other vapors?
Do you use pesticides, herbicides or other chemicals around your home?
Social Life
Enjoy job: Y N P
Hours worked per week:
Highest Level of Education:
Active spiritual practice: Y N P
Quality of significant relationship:
History of sexual, mental/emotional, physical abuse: Y N P If so, at what age and by whom:
What is your greatest health concern:
How does it limit you the most:
How committed are you towards making valuable changes:
Little
Moderately
Very
List all Supplements and Medications
Name and Brand
Dose
515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 
Hormone Review
Women’s Hormonal Symptoms: Please review the symptom checklist below and circle any symptoms you are experiencing
SYMPTOM
HEALTH CONCERN
Hot Flashes
Incontinence
Night Sweats
Bleeding Changes
Tearful
Tender Breasts/Fibrocystic Breasts
Uterine Fibroids
Depressed
Increased Forgetfulness
Water Retention
Mood Swings
Foggy Thinking
Estrogen Dominance
Stress
Decreased Stamina
Nervous
Headaches
Morning Fatigue
Anxious
Fibromyalgia
Sugar Cravings
Difficulty Sleeping
Irritable
Allergies
Dizzy Spells
Adrenals
Cold Body Temperature
Hair Dry or Brittle
Slow Pulse Rate
Infertility Problems
Goiter
Nails Breaking or Brittle
Rapid Heartbeat
Hoarseness
Constipation
Heart Palpitations
Thyroid
Scalp Hair Loss
High Cholesterol
Metabolic Syndrome/
High Androgens
Acne
Weight Gain – Hips
Elevated Triglycerides
Increased Facial/Body Hair
Weight Gain – Waist
Decreased Libido
Ringing in Ears
Decreased Muscle Size
Rapid Aging
Vaginal Dryness
Thinning Skin
Aches and Pains
Low Estrogen
Low Androgens/Other
Men’s Hormonal Symptoms: Please review the symptom checklist below and circle any symptoms you are experiencing
SYMPTOM
HEALTH CONCERN
Decreased Urine Flow
Weight Gain – Chest / Hips
Increased Urinary Urge
Weight Gain – Waist
Prostate Problems
Estrogen Dominance
Decreased Libido
Elevated Triglycerides
Decreased Stamina
Increased Forgetfulness
Sore Muscles
Rapid Aging
Decreased Erections
High Cholesterol
Night Sweats
Decreased Muscle Size
Increased Joint Pain
Thinning Skin
Ringing in Ears
Hot Flashes
Decreased Mental Sharpness
Decreased Flexibility
Bone Loss
Metabolic Syndrome/
Low Androgens
Burned Out Feeling
Evening Fatigue
Depressed
Irritable
Sugar Cravings
Stress
Difficulty Sleeping
Mental Fatigue
Nervous
Dizzy Spells
Morning Fatigue
Apathy
Anxious
Headaches
Adrenals
Cold Body Temperature
Hair Dry or Brittle
Rapid Heartbeat
Goiter
Constipation
Heart Palpitations
Hoarseness
Slow Pulse Rate
Infertility problems
Thyroid
515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 
711 N. Beaver Street Flagstaff, AZ 86001  (928) 779-3783  Fax: (928) 473-1082  www.northernaznaturalmedicine.com