INTAKE  FORM											

Chris Cooke, ND		

Natural medicine healthcare is possible only when the physician completely understands your physical, mental and emotional conditions.  The information you provide helps me understand your needs and how to help you reach your health goals.  Please write legibly and answer all questions to the best of your ability.  Feel free to mark anything you are uncertain about with a question mark.									
GENERAL INFORMATION																	
Patient's Name and Address:								

First	
Middle Initial  
Last

Address
City	
State	
Zip Code																
Telephone numbers:	
Home	
Work/Cell
E-Mail Address (optional): 	
SSN or Driver's License Number								
Date of Birth
Age	
Gender (check one)	
M	
F										

Number of children you have 																					
Occupation	
Hours per week

Marital Status
(put an "X" by the one that applies)						
Single	
Separated
Partnership
Married	
Divorced			

With whom do you live?									
	(put an "X" by the one that applies)						
Alone	
Parents	
Friends
Spouse	
Children	
Partner
					
Community activities in which you are involved:					

Emergency Contact:										
Name: 
Relationship: 											
Telephone Number 

When did you last visit a doctor's office, medical clinic or hospital?  Please explain.

Are you aware of any allergies to food, drugs or other environmental allergies (cats, mold, dust?)	 If yes, please list and explain.
							
What are your main health goals or concerns?																	
A. 	

B.

C.																
D.												

What timeline do you think is reasonable to achieve your goals or address your concerns?		

What do you expect from naturopathic care and from me as your doctor?	

												
I like to be in communication with your other health care providers, if possible.  Please list any other practitioners on your health care team that I may contact.											
A.		
Name		
Address															
Telephone Number								

B. 
Name:
Address:

Telephone number:												
Signature Electronic										
Date											

(Responsible party if patient is a minor)	

SELF AND FAMILY HISTORY										
What hospitalizations or surgeries have you had?				

What diagnostic imaging studies have you had?					
(put an "X" by the ones that apply)						

Bone density scan	
Mammogram
Electrocardiogram
Electroencephalogram
X-rays
CT scan
Colonoscopy or endoscopy	
Nuclear scan
MRI	
Ultrasound

Medications and/or Supplements							
 
Do you take any of the following?	
(put an "X" by the ones that apply)							
Pain relievers	
Antidepressants
Antacids	
Cortisone
Diet pills, appetite suppressants				
Thyroid medication
Laxatives	
Antibiotics (cream or pills)
Tranquilizers	
Seizure medication
Sleeping pills	
Hormones e.g. HRT, testosterone, steroids					

Please list any prescription medications, over-the-counter medications, vitamins, or other supplements you are taking.	

GENERAL									

Height 
Weight   lbs
Weight one year ago   lbs.
Maximum weight    lbs.  
When? 
Currently     lbs.

When during the day is your energy best? 
Worst?
Do you feel sleepy after meals?	
Yes					
No																					

Do you have particular lulls in energy during the day and if so, when? 

FAMILY HISTORY											

Do you have a family history of any of the following?
	(put an "X"" by the ones that apply)						

Anemia
Arthritis
Asthma
Cancer
Cataracts	
Epilepsy
Gallbladder disease
Glaucoma
Goiter
Hayfever/hives
Heart disease
Heart murmur	
High blood pressure	
Kidney disease	
Liver disease	
Mental illness
Stroke
Tuberculosis				

Is your father still living?
Yes, current age
No, age at time of death
					
Is your mother still living?
Yes, current age
No, age at time of death 									

CHILDHOOD ILLNESSES										

Please check whether you have had any of the following conditions as a child/adolescent:

Diptheria
German measles
Measles
Mumps
Rheumatic fever	
Scarlet fever					
Other (please list)									

PAST IMMUNIZATIONS

Please mark an "X" next to any of the following immunizations you have had. 	If unsure, please write a question mark beside the immunization.

Diptheria
Polio	
Measles/Mumps/Rubella (MMR)							
Tetanus	
Pertussis
Pneumonia
Yearly flu shots					
Other (please list)																											
REVIEW OF SYSTEMS											
Please mark an "X" next to any condition that was a past concern or is a current condition.										

Skin																	
Rashes	
Color changes	
Acne 
boils	
Eczema	
Loss of hair	
Skin tags
Lumps
Psoriasis
Itching	
Moles	
Hives
Night sweats							

Musculoskeletal																	
Joint pain	
Muscle spasms
Arthritis
Weakness	
Broken bones/fractures	
Sciatica					

Head															
General headaches	
Migraine headaches	
Head injury	
Jaw/TMJ problems			

Ears															
Ringing in ears	
Dizziness or vertigo
Earaches	
Impaired hearing					

Eyes															
Blurred vision
Color blindness	
Cataracts
Glasses/contacts	
Halos, sparks	
Eye pain/strain
Glaucoma	
Double vision	
Tearing/dryness
Spots in eyes								

Nose/Sinuses															
Stuffiness	
Nose bleeds	
Loss of smell	
Sinus problems	
Frequent colds	
Hayfever							

Mouth/Throat															
Hoarseness	
Jaw clicks	
Gum problems	
Dental cavities	
Sore lips/tongue	
Frequent sore throat		

Neck															
Lumps	
Swollen glands	
Goiter (enlarged thyroid)	
Pain or stiffness													

Respiratory															
Asthma
Wheezing	
Spitting up blood	
Productive cough with sputum								
Cough	
Bronchitis	
Pneumonia	
Difficulty breathing
Pleurisy/pain on breathing	
Emphysema	
Shortness of breath at night	
Shortness of breath lying down		
Need to sleep on pillows
Tuberculosis

Cardiovascular
Angina	
Fainting
Chest pain
Chest pain with exercise	
Low blood pressure	
Chest pain at rest	
Blood clots	
Ankle swelling	
Murmur						
Heart disease
High blood pressure	
Rheumatic fever						
			
Gastrointestinal

Diarrhea
Abdominal pain		
Constipation	
Thirst changes	
Liver disease	
Ulcers		
Black stool	
Heartburn	
Bloody stool	
Jaundice	
Nausea/vomiting	
Hemorrhoids	
Gall bladder disease			

How many bowel movements per day? 	

Urinary															
Painful urination	
Frequent urination	
Frequent urination (at night) 	
Frequent urinary infections	
Trouble with urination	
Difficulty holding urine	
Kidney stones				

Blood/Peripheral Vascular															
Anemia
Easy bruising	
Cold hands/feet
Thrombophlebitis	
Varicose veins 
Leg pain with walking

Neurological																							
Fainting	
Loss of memory
Numbness/tingling	
Muscle weakness	
Seizures										

Emotional															
Mood swings	
Depression
Nervousness						
Tension/stress	
Suicidal thoughts or plans
Anxiety						

Endocrine															
Hypothyroid	
Excessive thirst	
Cold intolerance	
Hyperthyroid	
Excessive hunger	
Heat intolerance	
Diabetes								

Male Reproductive										

Hernias	
Impotence	
Testicular masses
Discharge or sores
Venereal disease
Prostate disease								
Sexual difficulty	
Testicular pain	
Premature ejaculation								

Female Reproductive														
Date of last annual gyn exam								
Age of first menses 
Age of last menses (if menopausal)
Length of cycle (from first day of period until first day of next period):
Duration of menses (number of days of bleeding)					
Do you do self breast exams? 
Yes					
No
													
Number of pregnancies
Number of live births	
Number of miscarriages	
Number of abortions	
Cycles regular	
Painful menses	
Heavy flow	
PMS	
Bleeding between cycles	
Abnormal pap
Cervical dysplasia
Endometriosis	
Ovarian cysts	
Fertility issues	
Venereal disease	
Sexual difficulty	
Menopausal symptoms	
Breast lumps	
Breast lump(s)	
Nipple discharge	
Birth control	
Yes	
No													If so, what type?	

Sexually active											Yes					
       No																											
With:	
Men	
Women	
Both	

Is there anything else you would like me to know in order to serve you better?	

STATEMENT OF FINANCIAL RESPONSIBILITY																																												

The patient (or undersigned) agrees to pay all fees rendered at the time of service, either via cash, check, debit/credit card, or by special payment plan agreed upon by Dr. Cooke and the undersigned.  Since Dr. Cooke does not bill insurance at this time, patients are responsible for billing their insurance companies.  If NSF checks are deposited, the undersigned will be charged the overdraft charges incurred by Dr. Cooke.  Failure to remit payment for services after 90 days will be cause for termination of service.
			
I have read, understood, and agree to the terms in the financial agreement above.																																						

Signature of financially responsible party				

Date	

Please email to: drclcooke@comcast.net