Benna Lun BSc(Hons) ND Naturopathic Doctor
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- Mae Goodman
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1 Today s Date: PATIENT INFORMATION (Please print in block letters) Full Legal Name: First name Middle name Last name By what name do you prefer to be called? Date of Birth (MM/DD/YYYY): Current Age: Sex: Address: Street address Apartment # City Postal code Province Please provide your contact information below and indicate whether or not we may leave messages relating to your appointments: Message? Message? (H) Phone (C) Phone (W) Phone EMERGENCY CONTACT INFORMATION Name: Relationship: Phone numbers: H: ( ) OTHER: ( ) HOW DID YOU HEAR ABOUT DR. LUN? Website Referred by another patient Passing by clinic Referred by staff member Pamphlet/Flyer Referred by health care provider: Clinic patient Other (please specify: HEALTH CARE PROVIDERS Do you have regular screening tests run (e.g. annual physical, blood/urine tests)? (Please circle) Yes No Please list the health care providers from whom you currently receive treatment (complete as best you can): Page 1 of 6
2 Health care providers (continued) CHIEF CONCERNS Please list the top health care concerns for which you are seeking treatment in order of importance to you: MEDICAL HISTORY How is your general state of health? (Please circle) Excellent Good Average Fair Poor Please list any past health concerns, including major illnesses, hospitalizations, surgeries, etc., with approximate dates: Do you have any allergies (medication, seasonal, environmental, etc.)? (Please circle) Yes No If yes, please describe: If you are female, are you currently pregnant or are hoping to become pregnant in the near future? (Please circle) Yes No Page 2 of 6
3 Please complete the following table regarding medications and supplements: CURRENT medications Drug name Date started Dose What is this drug being taken for? PAST medications Drug name Date ended Dose What was this drug being taken for? CURRENT supplements (including vitamins, minerals, herbs, homeopathics, etc.) What is this supplement being Supplement name Date started Dose taken for? Do you regularly use any over-the-counter (non-prescription) medications? Please list: Page 3 of 6
4 Please complete the following table: Amount per day/week/month Caffeine (coffee, chocolate, tea, etc.) Tobacco (cigarettes, chewing tobacco, etc.) Alcohol (beer, wine, liquor, etc.) Recreational drugs (marijuana, cocaine, heroin, etc.) IMMUNIZATION HISTORY Is there anything remarkable about your immunization history? Please describe: Have you ever experienced a negative reaction from an immunization, including the flu shot? Please describe: DIET What do you eat on a typical day? Please indicate examples and quantities. Breakfast: Lunch: Supper: _ Snacks: _ Beverages: How are your meals usually prepared (Please circle)? At home Purchased Both Do you have any food allergies, sensitivities, or intolerances (that you know of)? (Please circle) Yes No Please describe: Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)? (Please circle) Yes No Please describe: Page 4 of 6
5 FAMILY MEDICAL HISTORY Please indicate any health conditions occurring in your family. Include parents, siblings, children, grandparents, aunts, and uncles. Health condition Heart disease (heart attack, stroke, etc.) Family member(s) High blood pressure Diabetes Asthma Eczema or other skin condition Thyroid disease (Hypo or Hyper?) Arthritis/Rheumatism/other muscle or joint condition Cancer (Please indicate type) Mental illness (e.g. depression, anxiety, schizophrenia, etc) Environmental/seasonal allergies Other (please describe): I don t know my family medical history LIFESTYLE What is your current occupation? Past occupation(s) that relate to your case? What are your hobbies? Please describe types and amounts of physical activity/exercise: Page 5 of 6
6 Are you exposed to significant amounts of smoke (including tobacco smoke) or other forms of pollution through work, hobbies, home environment, etc.? (Please circle) Yes No Please describe: Are you frequently exposed to animals (including pets)? (Please circle) Yes No Please describe: HOME: How would you describe the emotional environment in your home? STRESS: How stressful is your work and other aspects of your life? How well do you feel you handle stress? Is there anything you feel is important that has not been covered? Thank you for taking the time to complete this form Page 6 of 6
Adult Health History
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LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W
PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single
Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
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