The Heavens Declare His Handiwork

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Thomas Lee Abshier, ND

Naturopathic Doctor
Bioidentical Hormone Therapy

Libido, Energy

Menopause, Osteoporosis

Weight, Diabetes


1414 NE 109th Ave.

Portland, Oregon

(503) 255-9500

(503) 255-1888 fax

drthomas@naturedox.com

Naturopathic Medicine
The Holistic Healing Paradigm

Orthomolecular/Functional Medicine – (Hormones, Nutrition, Herbs, Homeopathy)

With the Goal of Restoring the Body’s God Given Pattern of Health
Removing the Resistance to Cure w/ Proper Nutrition, Lifestyle, Relationships, & Body Mechanics

Using Lab Tests & Clinical Judgement to Diagnose Errors of Metabolism and Genetics

Patient Intake Form: Part #1


Gateway to Health

NATUROPATHIC MEDICAL CLINIC

Thomas Lee Abshier, N.D.

Margo Diann Abshier, N.D.


Health History Questionnaire Instructions: 

Holistic health care and preventive medicine can be best delivered when the physician has a deep understanding of the patient on a physical, mental, emotional, and spiritual level.  Such analysis is only possible when you have detailed information about your past and present health issues.  Thus, it is requested that the following questionnaire be completed as thoroughly as possible.  Any question that seems significant should be answered; and if it is a more complicated than a yes or no answer, please give an explanation, and rate the significance of the symptom with a 1-10 rating.  Any question which was not understood should be indicated with a question mark. Ideally this questionnaire should be copied from the web page to a Microsoft Word document.  At that point you may type the information into the document next to the question, and email it to drthomas@naturedox.com, or fax it to 503 255 1888. 


Date of Intake: _____________


Identifying Information:

Name

Sex

Date of Birth

Address

City, State, Zip

Home phone

Business phone

Cell phone

Fax

email

SSN


Physical Data:

Age:

Height:

Weight:


Other Objective Physical Data - Current State:


Personal History:


Parents:


Siblings:


Live with:


Chief Complaints

1.

2.

3.

4.

5.


When and where did you last receive medical or health care? What was the reason?



Family Health Status:

Health: Good, Fair, Poor, age, age of death, medical condition

Father

Mother

Brothers

Sisters

Spouse

Children


Family Medical History 

Indicate the relative who had each of the following illnesses:


Childhood Illnesses: 

Indicate which diseases you contracted, the severity, and age


Serious Disease Syndromes:


Serious Infective Illnesses:


Traumas and Injuries:


Hospitalization and Surgery 


Imaging and Special Studies:

For what conditions have you had imaging done?

X-rays

CAT scan

MRI

Ultrasound

EKG: Electrocardiogram

EEG: Electroencephalogram


Immunizations:

Polio (Oral or Injection)

Pertussis

Tetanus shot (not antitoxin)

Diphtheria

Measles/Mumps/Rubella

Hepatitis

Chickenpox

Other


Allergies: 

Foods, food additives

Drugs

Contact allergens

Airborne allergens

MCS - Multiple Chemical Sensitivity (synthetic chemicals: smoke, exhaust, perfumes, detergents, carpet, paint...)


Current Prescriptions and OTC Medications:

Do you take or use the following drugs, and for the relief of what condition?

1.

2.

3.


Alternative and Prescription Medications:

Please list vitamins, minerals, herbs, amino acids, special nutrients, food concentrates, or other supplements you are taking:

1.

2.

3.


Exercise:

Types, duration, and frequency of exercise:

Cardiovascular: duration, type, heart rate, frequency of exercise

Flexibility: stretching, balance exercises (ball), gymnastics

Resistance: weights, repetitions, type, frequency, length of training


Healthy Habits

What are your main interests and hobbies?

Do you exercise? What forms? How often?

Do you eat three meals daily?

Sleep: Length (8 hrs/night, restful, and refreshing)? Dreams? Do you remember your dreams?

Enjoy your work?

Spend time outside? Enjoy nature? 15 minutes per day of sunshine?

Conversation? Friends, family, community, political involvement? Satisfying relationships?

Read? How many hours a day?

Vacations? How often, and how long?


Vices and Toxins:

Sugar: candy, pastries, soft drinks, cookies...

Watch television? How many hours a day?

Use caffeine? type, amount, frequency?

Use tobacco?  type, amount, frequency?

Use alcoholic beverages?  Frequency and consumption level?  Drink to the point of impairment or unconsciousness?  Treated for or struggle with alcoholism? 

Prescription drug dependence: narcotic pain pills (Vicodin, Percocet...), benzodiazopenes (Valium, Xanax...), barbiturates...

Use recreational drugs?  Your drug of choice?  Been treated for drug dependence?

Use Pornography? Excessive Gambling?  Excessive shopping?  Binge eating and purging?