Dr. Deborah Anderson, Naturopathic Physician ......DR. DEBORAH ANDERSON, ND NATUROPATHIC PHYSICIAN | FUNCTIONAL MEDICINE 252 SW Madison Avenue, Suite 180 Corvallis, OR 97333 P: 541-230-1351

DR. DEBORAH ANDERSON, ND NATUROPATHIC PHYSICIAN | FUNCTIONAL MEDICINE

252 SW Madison Avenue, Suite 180 Corvallis, OR 97333 P: 541-230-1351 | F: 541-435-0380 | [email protected]

COMPREHENSIVE MEDICAL HISTORY FORM

GENERAL INFORMATION:

Legal Name: ___________________________________________ Today’s Date: _________________

Preferred Name: ____________________________ Age: ______ Date of Birth: ___________________

Address: _________________________________________________ City: ______________________

State: ____________ Zip: __________ Email Address: _______________________________________

Home Phone: ________________ Cell phone: _________________ Other: ______________________

Relationship Status: ____________________ Name of Partner: ________________________________

Names/Ages of Children: _______________________________________________________________

EMERGENCY CONTACT: Name: ____________________________________ Relationship to You: ________________________

Home/Cell Phone: ___________________________ Work Phone: ______________________________

PRIMARY CARE PHYSICIAN / CONCURRENT MEDICAL CARE:

Primary Care Physician: _______________________________________________________________

Address: _________________________________________________ City: ______________________

State: ____________ Zip: __________ Phone: _____________________________________________

Date of last visit: _________________ Reason for visit: ______________________________________

Have you requested records to be sent to Dr. Deborah? Yes or No ________________

What other physicians, healthcare providers, or counselors/therapists are involved in your health care? (if you need more space, please use page 21):

Name, Date of Last Visit: _______________________________________________________________

Reason for Visit: _______________________________________________________________

Have you requested records to be sent to Dr. Deborah? Yes or No ________________________

Name, Date of Last Visit: _______________________________________________________________

Reason for Visit: _______________________________________________________________

Have you requested records to be sent to Dr. Deborah? Yes or No ________________________

© 2019 Dr. Deborah Anderson, ND Page " of "1 21



HEALTH CONCERNS:

Please list your most important health concerns in order of importance. List as much detail as you can including the following:

• When did the problem begin? • How has the problem changed or progressed? • What are your current symptoms? • What laboratory tests or diagnostic procedures have been done? • What are you currently doing to treat this problem?

(If you need more space, please use page 21)




CURRENT MEDICATIONS/SUPPLEMENTS:

Please list all prescription medications you are currently taking, including the dose, who prescribed this medication and the reason for taking it.

Please list all over-the-counter medications you take, including the dose, how often taken and your reason for taking it. (Ex: pain relievers, antacids, anti-histamines, sleep aids, laxatives, cold medications)

Please list all supplements you are currently taking, including the dose, how often, who prescribed this supplement and for what reason. If self-prescribed, please write self-prescribed.

Please list PAST prescription medications you took for more than a few months, approximate years, and reason for taking them. (Ex: antibiotics, pain medications, mood or psychotropic medications, hormonal birth control, etc)




FAMILY HISTORY:

Please list current ages, any health problems or diagnoses. If deceased, list the cause of death and at what age. Please write “unknown” if you don’t know.

Mother: ____________________________________________________________________________

Father: _____________________________________________________________________________

Siblings: ____________________________________________________________________________

Maternal Grandmother: ________________________________________________________________

Maternal Grandfather: ________________________________________________________________

Paternal Grandmother: ________________________________________________________________

Paternal Grandfather: ________________________________________________________________

Other than listed above, any known family history of cancer, diabetes, heart disease, high blood pressure, strokes, heart attacks, autoimmune disease or mental health disorders?

PAST MEDICAL HISTORY:

Did you receive the recommended vaccinations as a child? Any adverse reactions to a vaccination?

Have you received any vaccinations as an adult, such as a flu vaccine, HPV vaccine series, hepatitis vaccine, tetanus booster or vaccinations necessary for travel or work?

Have you had any injuries, car accidents, surgeries or hospitalizations in the past? If so, please explain.




Have you ever had any head injuries, head traumas or times when you’ve lost consciousness? Please explain.

Have you had any medical conditions or diseases in the past that are no longer part of your current health concerns? Please explain.

PREVENTATIVE EXAMS:

Have you had the following preventative physical exams? Please list the year of the exam and any abnormal findings. If normal, please list “normal”.

Full Physical Exam: ___________________________________________________________________

Gynecological exam/PAP: ______________________________________________________________

Mammogram or Breast Thermography: ____________________________________________________

DEXA Bone Density Scan (recommended for women over 50): _________________________________

Colonoscopy (recommended over 50): ____________________________________________________

Have you had any other diagnostic tests, such as an MRI, X-Ray, CT Scan, Ultrasound, Cardiac Stress Test, Sleep Study, or Endoscopy? Please list the approximate year and any abnormal findings. If possible, please request records from the facility that performed these diagnostic tests

TIMELINE: Please list general details of your health from infancy to adulthood. Include details of your health & major life events or stressors (i.e. parents divorced when I was four, moved at age seven, etc).

INFANCY 0-2 years old: Any difficulties with your mom’s pregnancy? Were you breast fed? If so, for how long? Any issues with sleep or eating? Any illnesses or injuries? Any other details your parents remember from your infancy?




CHILDHOOD through PUBERTY: Any major childhood illnesses such as chicken pox, strep throat, whooping cough, or recurrent ear infections? Any other significant life events during this time period or illnesses or injuries? How would you describe your childhood? What types of activities were you involved in?

PUBERTY through 20 years old: What details do you remember about puberty? How were your menstrual periods during this time? What kinds of activities were you involved in? Any major stressors, injuries or illnesses during this time? How would you describe this time in your life?

21+ through ADULTHOOD: What was the transition like when you left home? Any major illnesses, injuries, or significant life events? How would you describe your adulthood? Any major changes to job, lifestyle or marital/family status? Please use page 21 if you need additional space.




When was the last time you felt healthy? Please explain.

Were there any significant events (physical or emotional), injuries or illnesses that triggered your current health condition? For example, “I haven’t felt well since….”

ALLERGIES & SENSITIVITIES:

Are you allergic or hypersensitive to any of the following? Please use page 21 if necessary.

Any medications? ____________________________________________________________________

Any foods? __________________________________________________________________________

Any chemicals? ______________________________________________________________________

Any seasonal allergies? ________________________________________________________________

Any environmental allergies? ___________________________________________________________

ENVIRONMENTAL HISTORY:

Do you have any pets? What type? ______________________________________________________

Do you or a family member you’ve lived with have a known history of exposure to any harmful chemicals, including herbicides, insecticides, pesticides, organic solvents, or heavy metals?

Do you have any known history of significant exposure to mold in your home or workplace?

Have you noticed that your symptoms get better or worse at work, at home, on weekends, or on vacation? Please explain




SOCIAL HISTORY:

Occupation: ________________________________________________ Hours per week: __________

Employer: __________________________________________________________________________

Do you enjoy your work? _______________________________________________________________

Do you sit or stand for prolonged periods of time at work? _____________________________________

Have you retired? If so, when. ___________________________________________________________

If you have retired, what did you do for work? _______________________________________________

Have you ever travelled internationally? If so, where and when?

Do you currently or have you in the past smoked cigarettes? Please explain.

Have you had or are you currently exposed to secondhand smoke in your home or workplace? Explain.

Do you currently or have you in the past used recreational or illegal drugs? Please explain.

Have you ever had a problem with recreational or illegal drugs or been treated for a drug addiction? If so, please explain.

Do you currently drink alcohol? ________ If so, how many drinks in a typical week? ________________

What kinds of alcohol do you consume? Beer, wine, or liquor? _________________________________

Have you ever had a problem with alcohol or been treated for an alcohol related disorder? If so, please explain.




GENERAL INFORMATION:

Height: __________ Current Weight: _________ What do you consider your ideal weight: __________

Heaviest Adult Weight: __________ When was this? _________________________________________

Lightest Adult Weight: __________ When was this? _________________________________________

Have you ever struggled with your weight or had difficulty losing or gaining weight? Please explain.

Have you ever been on a diet? If so, when? Which ones? Please explain.

NUTRITIONAL HABITS:

Do you follow a typical diet plan (ex: Paleo, vegetarian, gluten-free)?_____________________________

How long have you been eating this way? _________________________________________________

Are there certain foods you avoid? _______________________________________________________

Have you ever had food sensitivity testing or done an elimination diet? Please explain.

How many meals or snacks do you eat on a typical day? ______________________________________

How often do you skip meals? ___________________________________________________________

What percentage of your weekly meals are eaten somewhere other than home? ___________________

Do you enjoy shopping, preparing, and cooking food? ________________________________________

Please describe what you typically eat for the following meals:

Breakfast: __________________________________________________________________________

Lunch: _____________________________________________________________________________

Dinner: _____________________________________________________________________________




Snacks: ____________________________________________________________________________

What are your favorite foods? ___________________________________________________________

List the 3 healthiest foods you eat in a week. _______________________________________________

List the 3 worst foods you eat in a week. ___________________________________________________

What types of foods are you most likely to crave? ___________________________________________

How many meals a week include desserts or surgery foods? ___________________________________

How much water do you typically drink during the day? _______________________________________

Please describe your intake of coffee, sodas, sugary drinks, fruit juices or tea.

In general, what is your appetite like throughout the day? Ravenous? Not hungry? Does it change?

In general, how do you feel after you eat? Tired? Refreshed? Bloated? Have Heartburn?

Have you ever had an eating disorder or an unhealthy relationship with food? Please explain.

On a scale of 1-5, (5 being very willing) how willing are you to make changes to your dietary choices? If you did not answer a “5”, what obstacles are preventing you from making those changes?

What is your biggest challenge around healthy eating? For example…Too little time to prepare or shop for food? Family doesn’t eat healthy? Don’t like vegetables? Not sure what foods are best for you?




What is the most important thing you feel you should change about your diet to improve your health?

Sleep:

How many hours do you typically sleep? ________ How many hours would you like to sleep? ________

What time do you usually go to bed? ________________ Get up in the morning? __________________

Do you have a consistent sleep routine? ______________________ Do you snore? ________________

Describe your sleep quality. Do you fall asleep easily? Wake in the night? Toss and turn? Grind your teeth?

Do you typically feel rested when you get up in the morning? __________________________________

What is your energy like during the day? In the morning? Afternoon? Evening? When are you most alert through the day? Does your energy dip in the afternoon or after meals?

Would you describe yourself as a morning, afternoon, or night person? __________________________

On a scale of 1-10 what is your average energy level like (10= tons of energy)? ____________________

Movement:

Do you exercise? _________ If so, how often? ____________ What types? ______________________

What are your favorite ways to exercise? __________________________________________________

What are your least favorite ways to exercise? ______________________________________________

Does exercise energize you or make you feel tired? __________________________________________

On a scale of 1-5 (5 being very willing), how willing are you to commit to daily movement or exercise? If you did not answer a “5”, what is preventing you from making this commitment?




Mood:

In general, are you an optimistic or pessimistic person? _______________________________________

How would you describe your typical moods? Are they stable or all over the place? Please explain.

Do you have a history of or are you currently experiencing depression, anxiety or a mood disorder? Please explain.

Stress:

How would you rate your stress level on a scale of 1-10? (10 = extremely stressed) _________________

What are the main sources of your stress?

Any significant stressful events in the last 10 years, such as a death in the family, divorce, job change, financial hardships or traumas?

How well do you handle stress? Do you currently use stress management techniques? Please explain.

BODY SYSTEMS: Please describe any symptoms you are CURRENTLY having OR have had in THE PAST FIVE YEARS. If you haven’t had any issues, please write NONE. If you need more room, please use page 21.

Please describe any symptoms or issues with your skin, hair and nails. Ex: Acne? Rashes? Itching? Dry skin, hair or nails? Hair Loss? Brittle Nails? Spots, ridges or discoloration of nails? Eczema? Psoriasis? Cold sores?




Please describe any symptoms or issues with your eyes, ears, nose, sinuses or mouth. Ex: Itching? Dryness? Redness? Ringing in ears? Hearing Loss? Stuffiness? Drainage? Chronic Sinus Issues? Frequent Nose Bleeds? Mouth Sores? Cavities? Bleeding Gums? Blurred Vision?

Do you have mercury (amalgam) filings? Have you had root canals?

Please describe any symptoms or issues with your respiratory system. Ex: Coughing? Wheezing? Asthma? Shortness of Breath? Hoarseness?

Please describe any symptoms or issues with your cardiovascular system. Ex: Irregular heartbeat? Murmurs? Palpitations? Chest pain? Swelling of hands or feet (edema)? Any history of high cholesterol, high blood pressure (hypertension) or low blood pressure (hypotension)?

Please describe any symptoms or issues with your hematologic system (blood). Ex: Anemia? Easy Bruising? Varicose veins? Hemorrhoids? Any history of blood clots or strokes?

Please describe any symptoms or issues with your digestive system. Ex: Difficulty Swallowing? Belching? Bloating? Gas? Nausea? Ulcers? Heartburn (GERD)? Abdominal cramping? Gall bladder or liver issues? Hemorrhoids? Irritable Bowel Syndrome or Disease?

Please describe your bowel habits. Ex: Constipation? Diarrhea? Alternating? Pain? Cramping? How often do you have a bowel movement? Do you ever see undigested food or blood in your stools?




Please describe any symptoms or issues with your immune system. Ex: Frequent colds or coughs? Poor wound healing? Swollen lymph nodes? Seasonal Allergies? Hayfever? Autoimmune disease?

Please describe any symptoms or issues with your urinary tract. Ex: Frequent Infections? Kidney Stones? Pain with Urination? Inability to Hold Urine? Do you leak urine when you cough, sneeze or laugh?

Please describe any symptoms or issues with your musculoskeletal system. Ex: Muscle pain? Soreness? Stiffness? Back pain? Joint pain? Swollen joints? History of broken bones? Osteoporosis? Fibromyalgia?

Please describe any symptoms or issues with your neurological system. Ex: Headaches? Migraines? Fainting? Dizziness? Seizures? Tingling? Numbness? Memory loss? Depression? Anxiety? Mood Disorders? ADD/ADHD? OCD? Tremors? Difficultly concentrating? Brain fog?

Please describe any symptoms or issues with your endocrine system. Ex: Adrenal fatigue? Thyroid issues? Heat or cold intolerance? Diabetes? Hypoglycemia? PCOS? Metabolic Syndrome? Cold hands and feet?

Reproductive Health (for Women): Age at first period: _______ Age at menopause (if applicable): _____ Mom’s age at menopause? ______

(If you’ve reached menopause, please answer the following based on how you remember your cycles.) What is the average number of days between periods? ______

How many days do you bleed? ________ Any bleeding or spotting between periods? ______________

Are your cycles regular or irregular? ________________________________ © 2019 Dr. Deborah Anderson, ND Page " of "14 21



How many pads or tampons do you use on your heaviest day of bleeding? _______________________

Please describe your typical period, including PMS symptoms in detail. If you are currently menopausal, please describe any symptoms or issues you are having with this transition. Ex: Moodiness? Cramping? Bloating? Heavy bleeding? Back pain? Passing clots?

Do you get night sweats or hot flashes? If so, how often?______________________________________

Please describe any symptoms or issues with your breasts. Ex: Tenderness? Soreness? Lumps? Fibrous changes? Discharge? History of cancer?

Please describe any symptoms or issues with your reproductive tract. Ex: Yeast infections? Vaginal itching or dryness? Infertility? Endometriosis? Ovarian cysts?

Number of pregnancies? ________ Miscarriages? ________ Abortions? _________ Births? __________

Do you currently use birth control? _________ If so, what type(s)? ______________________________

Are you happy with your current form of birth control? ________________________________________

What types of birth control have you used in the past? Any hormonal birth control? Any issues or problems with these types of birth control?

Do you or have you had any sexually transmitted infections (STI’s)? If so, please explain.




Please describe any difficulties you have with sex such as pain, vaginal dryness, delayed orgasms, or low libido.

Spirituality:

Do you have a spiritual practice? If so, please explain.

Does part of your day include: meditation, stillness, solitude, quiet moments, deep breathing, prayer or a gratitude practice?

Do you have people in your life that support your spiritual practice and encourage this part of your well-being? Please explain.

Surroundings (Community, Environment, Relationships):

Is a portion of your day spent outside and in nature? _________________________________________

Please describe your support network. Who do you have in your life that encourages, supports, and creates accountability for desired healthy lifestyle?

Does your primary relationship support your desire to enjoy a healthier life? Are there ways you do not feel supported? Please explain.




Do you enjoy your work and daily activities? Do you enjoy good working relationships with your co-workers? Have you made any significant occupational changes in the last 10 years?

Toxicity: What kind of cleaning products and/or chemicals do you use in your home (& yard) regularly?

Do you use non-toxic makeup and/or personal care products. If you are gluten-sensitive have you verified that all your products are gluten-free?

What kind of cookware do you use? Stainless steel, non-stick, cast-iron, copper? Do you store foods in plastic or glass?

How much of your food is organic? Are there certain foods that you always buy organic or conventional? Meat? Dairy? Vegetables/Fruits? Oils/Nuts?

Do you wear perfumes and/or use scented candles or air fresheners in your home? Please explain.

Do you have an air filter or filtration system in your home? How often do you change furnace filters?




Do you use a water filter or have a filtration system in your home? If you use well water have you ever tested your water?

Self-love:

Do you spend time doing things that nourish, rejuvenate, and satisfy the deepest part of your being? Please explain.

Do you make a conscious effort to include time for rest and play (in your day, week, and year)? Explain.

Are you kind and loving to yourself? Do you consciously express self-compassion, forgiveness, unconditional love and acceptance toward yourself. Please explain.

WORKING TOGETHER: (Help me Help you!).

Please explain your familiarity with alternative, naturopathic and functional medicine.

What are you hoping my role will be in your healthcare?




What do you expect from me?

What can I do to help you feel supported?

How open/willing are you to explore that the root causes of your health imbalances may not be purely physical? (Ex: mental, emotional, or spiritual)

THE GOOD STUFF:

Are there ways that you knowingly sabotage your own health? What things do you do that are destructive to your health and healing?

What things do you do that support your health and healing?

What is your life purpose? In other words, what do you need your health for?




Finish this sentence: A year from now, I’m hoping…

Finish this sentence: In five years from now, I’m hoping…

What do you think has caused your current symptoms and health challenges? In other words, what do you think are your root causes?




ANYTHING ELSE?

Please use this space to tell me any more information that you think I need to know. What questions did I forget to ask you?


Documents

Dr. Deborah Anderson, Naturopathic Physician ......DR. DEBORAH ANDERSON, ND NATUROPATHIC PHYSICIAN | FUNCTIONAL MEDICINE 252 SW Madison Avenue, Suite 180 Corvallis, OR 97333 P: 541-230-1351