Dr. Christine C. White Dr. Elizabeth Axelrod Black Bear Naturopathic Clinic, PC

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