Bastyrcenter.org

Patient Profile
Last Name: ________________________ First Name: _______________________________ Middle Initial: ____________ Nickname: _________________________ Date of Birth _______ / _______ / _______ Gender: _______ A note to our patients: Please complete this 3-page questionnaire as thoroughly as possible in order to aid your clinician
in their diagnosis and treatment. This is a confidential record of your medical treatment and will not be released, except if you have provided us with written authorization. Thank you for your help. What goals do you have for your visit at the clinic today? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Who is your Primary Care Provider?____________________________________________Phone: ( ____ ) ________________ Please list other providers/specialists involved in your care and their clinic phone number: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ If you are seeking adjunctive Cancer support, who is your Oncologist? Oncologist? ________________________________________________________________Phone: ( ____ ) ________________ When was your last physical? ______________________ When did you last have bloodwork? _______________________ Please indicate the type of care you are seeking  Primary management of my health  Adjunctive care for my health  On-going management of my health  One time advice for my health Have you ever consulted a Naturopathic Physician, Acupuncturist, Nutritionist or Counselor before?  Yes  No If YES, please circle which type of practitioner you’ve previously consulted with. In general would you say your health today is:  Excellent  Very Good  Good  Fair  Poor Patient Profile
Last Name: ________________________ First Name: __________________________Date of Birth _____ / _____ / _______ Do you have any medication allergies or any allergic reactions to anything else?  Yes  No
If YES please explain: ____________________________________________________________________________________
_______________________________________________________________________________________________________ Please list all medications and supplements you are taking including prescriptions, over-the-counter medications,
vitamins, minerals, herbs and homeopathic remedies. Attach another page if needed. Name of medication
Strength
Directions
(such as Synthroid, Vitamin D, etc.) (such as 1 tablet twice a day, as needed, etc.) Medical History
Please check box to indicate if you or a family member has ever had the following conditions. If condition does not
apply leave blank. Please indicate which relative has the condition, if applicable such as mother (M), father (F), sibling
(S) or maternal or paternal grandmother/grandfather (MGM, MGF, PGM, or PGF).
Condition
RELATIVE
Condition
RELATIVE
Patient Profile
Medical History continued
Last Name: ________________________ First Name: __________________________Date of Birth _____ / _____ / _______ Condition
RELATIVE
Condition
RELATIVE
Please list any surgeries or hospital stays you have had and their approximate date/year:Type of surgery/reason for hospitalization: Date: _____________________________________________________________________ _______ / _______ / _________ _____________________________________________________________________ _______ / _______ / _________ Social History
Do you use any of the following substances regularly?
 Coffee/Black Tea/Cola  Alcohol  Recreational Drugs  Tobacco- Current/Past/Never If Current or Past Tobacco Use: Packs Per Day: _______ How Long: _______ Quit: __________________ Please mark those that apply:  Single  Married  Significant Other  Divorced Other: ____________________ Do you have children?  Yes  No If YES, what are their ages: ______________________________________________ Do you follow any particular diet restrictions? Yes No If Yes, please describe: ___________________________ ____________________________________________________________________________________________________ Do you exercise regularly? Yes No If YES, please describe type of exercise and how often. _____________________ ____________________________________________________________________________________________________ ___________________________________________________________ ________________________________________ Patient/Guardian (Print Name): Date
___________________________________________________________ ________________________________________ Patient/Guardian Signature: Date of birth
Reviewed by Provider and ready to be scanned to EPIC (Initals): __________________ Date: _______ / _______ / _________

Source: http://www.bastyrcenter.org/bcnhForms/FORMpatientprofile2013.pdf