New Patient Adult Intake Form (Ages 13+)

North Seattle Natural Medicine

617 5th Ave S. Edmonds, WA 98020

Phone: 206-629-5180
Fax: 206-629-5197

Basic Information

First name

Last name

Date of Birth

Age

Preferred gender pronoun(s)

Gender assigned at birth

Male

Female

Phone number (if under 18, parent/guardian)

Parent/Guardian name (if patient is under 18)

I consent to detailed voice messages being left on my voicemail for my phone number listed above. This permission may be rescinded at any time. Please contact the clinic if you wish to rescind.

Yes

Email address (if under 18, parent/guardian)

Address 1(if under 18, parent/guardian)

Address 2

City

State

Zip code

Height

Weight

Number of children

Ages of children (if applicable)

Allergies to drugs, food, or other substances

Describe

Current living situation (i.e. spouse, roommate, domestic partner, etc.)

What do you do for work?

Which doctor would you prefer to see?

If your preferred doctor is not able to accept new patients at this time, which doctor would be your secondary preference?

If your preferred doctor is Dr. Zampiello or Dr. Nguyen, are you interested in acupuncture as part of your care?

Insurance company network/plan name

Have you verified that your insurance will cover your preferred doctor at North Seattle Natural Medicine?

Please note, due to the differences in each patient's insurance plan we rely on you to know your coverage. You can visit our website at https://www.northseattlenaturalmedicine.com/insurance to verify your insurance!

I acknoweldge that it is my responsibility to confirm that my preferred doctor is in network with my specific insurance plan and if my plan will cover visits with said doctor before my first appointment/upon renewing my insurance.

List your current health concerns (prioritize in order of importance)

Are you experiencing any acute pain? If this is a medical emergency, please call 911.

Yes

Please describe

Problem #1

Concern

Date of onset

Describe

Cause

Where are you feeling pain/discomfort? (i.e. head, neck, stomach)

Type of pain/discomfort (i.e. aching, numbness, stabbing pain)

Regularity

Status

Why is it worsening or improving?

Prescription/surgery/treatments tried & the results

Related personal and/or family history

How does problem #1 affect your body/life?

Problem #2

Concern

Date of onset

Describe

Cause

Where are you feeling pain/discomfort? (i.e. head, neck, stomach)

Type of pain/discomfort (i.e. aching, numbness, stabbing pain)

Regularity

Status

Why is it worsening or improving?

Prescription/surgery/treatments tried & the results

Related personal and/or family history

How does problem #2 affect your body/life?

Problem #3

Concern

Date of onset

Describe

Cause

Where are you feeling pain/discomfort?(i.e. head, neck, stomach)

Type of pain/discomfort (i.e. aching, numbness, stabbing pain)

Regularity

Status

Why is it worsening or improving?

Prescription/surgery/treatments tried & the results

Related personal and/or family history

How does problem #3 affect your body/life

General Information

Have you seen a naturopathic doctor before?

Are you currently seeing a naturopathic doctor?

Doctor's name and office (if applicable)

Do you have a medical doctor?

Doctor's name and office (if applicable)

Do you see any other healthcare professional (i.e. chiropractor, acupuncturist, massage therapist, counselor)?

Explain

Do you have any other current medical conditions or symptoms? (Please list)

Do you have any spiritual or religious beliefs that affect your diet or health practices?

Average daily diet (breakfast, lunch, dinner, beverages).

How many hours a week do you exercise?

Tobacco use

Type

Smoke

Chew

Number of years

Amount per day

Year stopped

Notes

Alcohol use

Type

Frequency

Year stopped

Notes

Recreational drug use

Type

Frequency

Year stopped

Notes

Are you sexually active?

Are you sexually active with

Men

Women

Both

Other

How many sexual partners in the last year?

Medical History

List the prescription and non-prescription medications, birth control, vitamins, minerals, and herbs that you are currently taking (include the dosage of each)

Please specify your preferred pharmacy

Preferred pharmacy's phone number

List any medications that have been prescribed but you are not taking

List any major illnesses, hospitalizations, surgeries, or serious injuries (include date and brief description)

Review of Systems

Are you experiencing any of the following? Fever/chills/night sweats, unexpected weight loss, visual disturbances, itching, pain, discharge from the eyes, heart palpitations, chest tightness/pain/shortness of breath, symptoms of asthma, hay fever, lung infections (bronchitis/pneumonia), frequent colds or flu, nausea, gas/bloating, constipation/diarrhea, rashes, eczema, psoriasis, hives, acne, frequent bladder/kidney infections, stiffness/aching in muscles and joints, headaches/migraines, numbness/tingling, easy bruising, tendency for anxiety, depression, irritability, other. Please list.

Family Medical History

Please list any known family medical conditions (i.e. cancer, asthma, heart disease, kidney disorder, etc.) and who was affected (i.e. father, mother, siblings, grandparents).

Over the last two weeks how often have you experienced any of the following problems?

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

How did you learn of us?

Would you like to be added to our Newsletter? (Includes updates, specials, and sales!)

Yes

Thank you for filling out our New Patient Intake Form! Once you have submitted it you should expect to hear from us within 5 business days. If you have any questions feel free to give us a call. We'll talk to you soon!

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