Dr. Christine C. White Dr. Elizabeth Axelrod Black Bear Naturopathic Clinic, PC 2831 Fort Missoula Road Suite 105, Missoula, MT 59804 New Patient Health History Name Date Preferred Name Age Gender Date of Birth Pronoun Preference Social Security # Address ____City Telephone—Home ____State_____ Zip Work Cell May we leave medical related information on your voicemail? Email Address Yes No ____________ May we contact you by email? Yes No Occupation/Former Occupation Full-time Part-time Employer Name & Address Married Separated Single Divorced With whom do you live? Spouse/Partner Children Widowed Alone Partnered Parents Relatives Emergency Contact Friends Relationship Address Telephone—Home How did you hear about us? Work Family/Friend Cell Missoulian Independent Website Phone Book If you were referred by someone, let us know who so we can thank them Name of Primary Care provider: ___________ Approx Date of Last visit When, where and by whom did you last receive medical care? ________ Primary reason for this visit In your opinion, what are your most important physical, emotional, and/or mental health problems? 1._________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4.__________________________________________________________________________________________ How do you rate your overall health? Excellent What are you expectations for today’s visit? What are your expectations for our work together in general? Good Fair Poor Dr. Christine C. White Dr. Elizabeth Axelrod Hospitalizations What hospitalizations or surgeries have you had? When did they occur? Special Studies What diagnostic imaging studies have you had? (x-rays, CT scan, mammogram, MRI, bone density, EKG, EEG) Medications, Supplements, Herbs List all drugs, vitamins, herbs being taken at present with dosage Are you allergic to any medications or other substances? Yes No If yes, please list Childhood Illnesses Rubella (German 3 day measles) Measles (2 week) Polio Rheumatic Fever Scarlet Fever Asthma Mumps Chickenpox Eczema Roseola Whooping Cough Frequent Ear Infections Other? Any difficulties with your birth or your mother’s pregnancy with you? Immunizations Unsure, probably all of them Polio Pertussis Tetanus Diphtheria Measles/Mumps/Rubella Other? 2 Dr. Christine C. White Dr. Elizabeth Axelrod Your Health History Current Past Current Past Allergies Anemia Arthritis Alcoholism Bleeding problem Cancer Candida Colitis Drug/Alcohol Use Eczema Emphysema Headache Head Injury Family History My mother’s health is: Good My father’s health is: Good Fair Fair Heart murmur High blood pressure Injury--Serious Kidney disease Liver disease Overweight Pneumonia Polio Rheumatoid Arthritis Thyroid disorder Tuberculosis Sexually transmitted infection Other Poor Poor Deceased Deceased Has any Blood Relative had any of the following? Yes No Unsure Anemia Arthritis Asthma Bleeding disorder Cancer—Type Yes No Unsure Hay fever Heart attack High blood pressure Seizure disorder Diabetes Eczema Glaucoma Gout Sickle cell anemia Thyroid disease Tuberculosis Social History Have you traveled outside the USA? When/Where Did you serve in the military? Yes No If yes, where/when Do you have a religious or spiritual practice? Overall stress level: Low Average In what areas of your life do you experience stress? High Work Family Relationships Social Financial School Please list the 4 most significant stressful events of your life, including childhood stressors. 1._________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. _______________________________________________________________________________________________ 4.________________________________________________________________________________________________ 3 Dr. Christine C. White Dr. Elizabeth Axelrod Health Habits Number of alcoholic drinks per week, on average: If so, what? Beer Wine Non-drinker 0-1 1-5 5-10 10+ Distilled Do you use tobacco or have you used it in the past? Yes No If so, how many packs/tins per day Total number of years tobacco use Total number of years since you stopped? Circle any of the following that you do on a regular basis: Jog Breathing exercises Stretching _______ Walk Weight Lifting Martial Arts Swim Bicycle Garden Hike Yoga Hunt Fish Other How do you relax? Primary Hobbies? Sleep Patterns (circle): less than 6 hours 6-8 hours 8+ hours light sound can’t fall asleep can’t stay asleep Diet Number of meals eaten per day? 1 How is your appetite? Good 2 Poor 3 More than 3 Excessive Who cooks the food you eat? If you eat out, where do you go? Any diet or food restrictions /special diets you follow? List the foods excluded from your diet or the ones you avoid Amount of water you drink daily Do you drink soda? What, diet/regular Do you drink coffee/regular/decaf/how much? What about your diet do you believe needs to be changed? Home Environment and Other Environmental Exposures Circle any of the following that apply to your primary dwelling or life in general Gas heat Water quality? Oil heat Distilled Wood Stove Filtered Spring Electric heat Well Air Conditioning Deionized Ozonated Electric Blanket TV Tap Do you have a New Car or New Home? Do any of the following bother you? Sunshine Loud noise Crowds Lack of sunshine Dampness Dryness Heat Dust Mold Cat hair Dog hair Exhaust Fluorescent lighting Chemicals Cold Perfumes 4 Dr. Christine C. White Dr. Elizabeth Axelrod Reproductive Health Male Are you currently sexually active? Yes No Past, not currently Type of contraception used? Are you satisfied with your contraception? Yes No Are you concerned about the possibility of a sexually transmitted infection? Yes No Are you taking hormones of any kind? Yes No If yes, type and dose Do you have any of the following? Testicular Pain Prostate Pain Hernia Sexual desire: Penile Discharge Genital Sores 0 1 2 3 4 5 6 7 8 9 10 (0=none) Sexual function: Great, no complaints Starting to have troubles Erectile dysfunction Female Are you currently sexually active? Yes No Past, but not currently Type of contraception used? Are you satisfied with your contraception? Yes No Are you concerned about the possibility of a sexually transmitted infection? Yes Have you ever used—oral birth control pills Norplant Are you currently using—oral birth control pills No Depo-Provera No to all of these options Norplant Depo-Provera Are you using hormone replacement therapy? Yes No If yes, type and dose Age when menstrual periods started You get your period every Your periods last Did you have a normal puberty? days. Regular cycles? Yes No days, on average. Date of your last period Cramping Yes No Severe Quality and quantity of flow—dark red, bright red, clots, very light, very heavy Are you post menopausal (no period for 12 consecutive months)? Yes No Maybe PMS Yes No Impacts my life every month Approximate date of last PAP Have you ever had an abnormal PAP? Yes Do you have any concerns about your ability to conceive? Yes No When No Any chance you are pregnant now? Yes No Unsure Number of pregnancies Births Miscarriages Abortions Any pregnancy complications? Yes No Briefly explain any complications History of vaginal infections: Bacterial Vaginosis (BV) Sexual desire Sexual function: Yeast Chlamydia Gonorrhea Herpes HPV 0 1 2 3 4 5 6 7 8 9 10 (0=none) Great, no complaints Starting to have troubles Trouble Any breast health concerns? Date of last mammogram, if applicable: 5 Dr. Christine C. White Dr. Elizabeth Axelrod Medical History: Please Circle O for Occasionally, Y for Yes, P for Past condition (not current); Leave the rest blank General Weight………………………. Weight one year ago…. Maximum Weight……… When………………………… Height……………………….. Significant fatigue…….. Night sweats…………….. History of cancer………. Recent weight loss…… Recent weight gain……. Fevers………………………. Autoimmune illness…. Genetic condition…… O O O O O O O O Y Y Y Y Y Y Y Y P P P P P P P P Skin Recurrent Rashes……. Eczema……………………. Hives……………………….. Chronic Itching………… Lumps…………………….. O O O O O Y Y Y Y Y P P P P P Head/Neck Recurrent headaches.. Head Injury……………… Swollen glands………… Goiter……………………… Chronic pain/stiffness Whiplash………………….. O O O O O O Y Y Y Y Y Y P P P P P P Eyes Eye pain……………………. Tearing/dryness………… Double vision……………. Glaucoma………………….. Cataracts…………………… Corrective lenses……… O O O O O O Y Y Y Y Y Y P P P P P P Ears Hearing loss………………. Ringing/tinnitus………… Earaches…………………… Chronic ear infections.. O O O O Y Y Y Y P P P P Nose/Sinuses Frequent colds………….. Nose bleeds………………. Chronic Stuffiness……… Hay fever…………………… Sinus infections…………. Sinus surgeries………….. O O O O O O Y Y Y Y Y Y P P P P P P Mouth/Throat Frequent sore throat…. Sore tongue……………… Bleeding gums…………… Gum disease……………… Chronic hoarseness……. Dental cavities…………… Root canals……………….. Last dental exam……… O O O O O O O Y Y Y Y Y Y Y P P P P P P P Respiratory/Lungs Chronic cough……………. Chronic mucus………….. Coughing blood…………. Wheezing………………….. Asthma……………………… Bronchitis………………….. Pneumonia……………….. Pleurisy……………………….. Emphysema………………… Difficulty breathing……… Pain with breathing…….. Short of breath……………. O O O O O O O O O O O O Y Y Y Y Y Y Y Y Y Y Y Y P P P P P P P P P P P P Cardiovascular Heart disease……………… Angina/Chest pain………. Hypertension………………. Murmurs…………………….. Rheumatic fever…………. Ankles swelling……………. Skipped/ irregular beats Fainting……………………….. High Cholesterol………….. O O O O O O O O O Y Y Y Y Y Y Y Y Y P P P P P P P P P Urinary Pain with urination……… Increased frequency…… Frequency at night…….. Urgency/unable to hold. Bladder/Kidney infections……………………… Kidney stones………………. Circulatory Easy bruising………………… Anemia………………………… Cold hands/feet………….. O O O O Y Y Y Y P P P P O Y P O Y P O Y P O Y P O Y P Arms/Legs Deep leg pain………………………… Varicose veins………………………. Blood clots/thrombophlebitis Nail fungus…………………………… Restless legs…………………………. Pain with walking……………....... O O O O O O Y Y Y Y Y Y P P P P P P Gastrointestinal Belching………………………………… Gas……………………………………….. Gall bladder pain/removed Heartburn/Reflux………………… Indigestion…………………………… Liver disease/problems………… Jaundice……………………………….. Vomiting………………………………. Blood in stool……………………….. Hemorrhoids…………………………. Binge eating………………………….. Abdominal/stomach cramps…. Constipation…………………………. Diarrhea………………………………… # of bowel movements a day O O O O O O O O O O O O O O # Y Y Y Y Y Y Y Y Y Y Y Y Y Y P P P P P P P P P P P P P P Muscles/Bones/Joints Joint pain/stiffness……………….. Arthritis………………………………… Muscle cramps……………………… Weakness…………………………….. Frequent injury…………………….. Bone loss/Osteoporosis……….. O O O O O O O Y Y Y Y Y Y Y P P P P P P P Nervous System Seizures……………………………….. Numbness /tingling……………… Memory loss…………………………. Balance problems………………… O O O O Y Y Y Y P P P P Endocrine/Hormones Hypothyroid………………………….. Hyperthyroid………………………… Low blood sugar……………………. Diabetes……………………………….. PCOS……………………………………… Chilly, cold hands and feet……. Hot and sweaty…………………….. Metabolic Syndrome…………….. O O O O O O O O Y Y Y Y Y Y Y Y P P P P P P P P 6 Dr. Christine C. White Mood Panic Attacks…………….. ADD/ADHD……………… Anxiety……………………… Anger Issues……………… Bi-polar…………………….. Irritability………………….. Depression……………….. Weepy………………………. Dr. Elizabeth Axelrod O O O O O O O O Y Y Y Y Y Y Y Y P P P P P P P P Reproductive-Female Endometriosis………………. Breast Cancer………………. Fibrocystic Breasts……… Fibroids………………………. Genital Herpes……………… Vaginal Dryness……………. Hysterectomy………………. Infertility……………………… Pain with intercourse….. Breast tenderness………… Low libido……………………. Ovarian cyst………………… O O O O O O O O O O O O Y Y Y Y Y Y Y Y Y Y Y Y P P P P P P P P P P P P Reproductive-Male BPH……………………………………… Genital Warts………………………. Lesions………………………………… Erective Dysfunction……………… Prostatitis……………………………… Genital Herpes………………………. Low libido……………………………… O O O O O O O Y Y Y Y Y Y Y P P P P P P P Please Initial and Sign: I authorize Dr. Christine C. White and/or Dr. Elizabeth Axelrod to examine and treat me. I understand that the treatments and therapies provided or recommended by this clinic may be different from those offered by another licensed health care provider, and that I am at liberty to seek other care as well. I understand that payment is expected at the time of service. If I choose to submit billings to my insurance company, I consent to the release of all information the insurance company may request for the filing of insurance claims. Patient Signature Date Responsible Party, if other than the patient Date 7