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Grand Rapids Natural Health, LLC 638 Fulton St W Suite B Grand Rapids, MI 40504 T (616) 264-6556 www.grnaturalhealth.com F (616) 432-3564 GRAND RAPIDS NATURAL HEALTH INITIAL PAPERWORK Patient Name Age Address City Daytime Phone Occupation Date of Birth State Evening Phone Cell Phone Employer Email Address: Emergency Contact: / Phone: How did you hear about us? Reason for visit today? Primary Health Concerns: (In order of importance) 1. 2. 3. 4. Medical History Allergies: (Medications, Food, Environmental) Please list Past Surgeries and/or Hospitalizations: 1) Date: 2) Date: 3) Date: / Sex: F M Zip Please List the Medications you are currently taking: (with dosage) 1) 2) 3) 4) 5) Primary Care Screening Exams: When was your last- Last Eye exam: Last Dental exam: Last Pap and Mammogram: Last DEXA: Last DRE: Last Blood work: Please list the supplements you are taking: (with dosage) 1) 2) 3) 4) 5) Family History Please list any significant health concerns for the following relatives. Age (if alive) Father Mother Siblings Maternal Grandfather Grandmother Aunts/Uncles Age(at death) Health Problems Paternal Grandfather Grandmother Aunts/Uncles Social History Food allergies: Drug allergies: What happens: What happens: Use of the following (circle what applies and write C for current use, P for past use, and indicate how much): Cigarettes Recreational drugs Alcohol Other Water Intake in ounces daily Sleep: Circle all that apply: Coffee (cups/day) Difficulty falling asleep Waking Frequently Waking unrefreshed Bowel Movements: Number per day Circle all that apply: Undigested food Mucous Exercise: Frequency/week Types: Personal Birth History: Circle one: Vaginal Birth/C-section Blood Breast fed/Formula fed Approximate Rounds of Antibiotics Taken in Lifetime: Review of Systems Please mark now (W) or past (P) next to all areas that apply to your past and present health. HEENT headaches dizziness blurry vision fainting/blackouts loss of balance eye pain/red eye cataracts/glaucoma Chest wheezing cough up blood heart palpitations Gastrointestinal stomach pain indigestion nausea blood in vomit yellow skin/jaundice earaches ringing in ears difficulty hearing nosebleeds loss of smell hoarse voice grinding teeth neck lumps/swelling dental problems sore throat sore/bleeding gums difficulty swallowing cold or canker sores high blood pressure swollen ankles chest pain shortness of breath chest colds chest pain constipation diarrhea vomiting gas/bloating clay colored stool loss of appetite excessive appetite blood in stool light colored stool rectal pain/itching Genitourinary frequent urination urge to urinate incontinence difficulty urinating Musculoskeletal aching muscles numbness/tingling restless legs blood in urine kidney stones sexual difficulty pain with urination bladder infections genital sores STDs genital discharge broken bones weakness swollen joints sore joints leg cramps tender point Skin acne itching Endocrine always cold always hot rashes lesions easy bruising hives chronic fatigue weakness increased hunger increased thirst Nervous anxiety loss of sensation tremor foggy thinking lack of strength convulsions loss of memory lack of concentration paralysis Blood, Immune painful lymph nodes frequent bleeding anemia fluid retention swollen glands wounds heal slowly Male Reproductive prostrate problems painful erections painful urination infertility discharge difficult/premature ejaculation swelling in testicles Female Reproductive lumps in breast(s) breast pain missed periods lack of sexual desire pelvic pain Mental/emotional depressed mood suicidal thoughts angered easily afraid of being alone shy/timidity vaginal discharge heavy periods genital eruptions pain with intercourse vaginal itching/burning restlessness excessive worry loneliness critical of others scary dreams painful testicles trouble maintaining erection spotting between periods difficulty having orgasms mental confusion mood swings frequent crying suspicious/jealous confident/secure