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Intake Forms In preparation for your first visit, we would like you to fill out our initial Intake Form. You can obtain a copy below. When completed, you can send it to us by mail, email or fax. Mail: Email: Fax: Please note that the information gathered is completely confidential. From Dr. Namaya: I am a Classical Homeopath and a board certified Family Nurse Practitioner. In addition, I have studied traditional Chinese Medicine, Western herbal medicine, and Aruyvedic. I integrate my experiences in medicine, counseling, and healing over the past 30 years and bring them to the service of my clients (patients). I provide comprehensive compassionate wholistic medical care based on the principles of classical homeopathy. Classical homeopathy is a two hundred year old medical science that looks at the whole person: mind, body, and spirit and then determines the most appropriate form of treatment. We also incorporate the best methods from Western (allopathic) medicine and as appropriate use laboratory, x-ray and other diagnostic tools. The initial intake that you will fill out (below) will cover your basic medical and personal history. Try to fill out the form as completely as possible. You and I will try to arrive at a true and in-depth understanding of you and your illness. My aim is to genuinely see what are the sources of the problem and based on that suggest a treatment. This healing requires your active participation with the suggested program. Based on these discussions generally I make recommendations regarding your diet, changes in lifestyle, health practices, and where appropriate a homeopathic remedy. My goal is to not only help you transform your health. I look forward to working with you. Sincerely,
INITIAL PATIENT INTAKE FORM When completing this Patient Intake Form, please provide as much detail as you can give as the additional information is very helpful in understanding your health. Record all food and drink for three days prior to the visit. Bring medical or lab reports that that are relevant and any medicines you are taking. Also, bring your insurance card. THIS INFORMATION IS PART OF YOUR MEDICAL RECORD, AND BY LAW, CANNOT BE RELEASED OR DISCLOSED WITHOUT YOUR PERMISSION: Name: _______________________________________ M/F: ___ Other Medical or Health Providers you have seen within the last 5 years: ___________________________________________________________________ PAYMENT: Payment or insurance billing information is due at the time of initial visit. If you need to schedule payment or are having difficulty with payment, please contact the provider. I. MEDICAL REASON(S) FOR VISIT What is the medical reason for your visit? _____________________________________________________________________ How long have your had this condition? _____________________________________________________________________ Current RX/Herbs/Homeopathic Vitamins: _____________________________________________________________________ Significant Health Problems: In chronological order _____________________________________________________________________ ALLERGIES:
(Food, MEDICATION, Environmental) How long have your had them? _____________________________________________________________________ What do you take for them? _____________________________________________________________________ How do your allergies affect you? _____________________________________________________________________ II. REVIEW OF SYSTEMS Headaches? FOR THE FOLLOWING QUESTIONS: Please check off yes or no if you have problems in the following areas. If yes, briefly describe. Sinus: Sinus tenderness? OINTS: Arms: _____ Shoulder:
_____ ADDITIONAL PROBLEMS:___________ III. LIFESTYLE Stress Joy Sleep IV. FAMILY HISTORY Significant Family History of Illness: MOTHER: Alive:_____ Age: Parents: Smokers? Birth: Any unusual problems at birth? Premature? Other? Vaccinations: Significant Health Problems as a child? Social History Please fill out to your degree of comfort; this information is confidential and helpful. Do you have a consistent network of family or friends you can rely on for support? Personal use of alcohol: How often? Amt. Personal use of marijuana, drugs or narcotics? Past? __________ Present?
__________ Tobacco use: Sexuality: Are you involved in a satisfying relationship? EXERCISE: What do you like to do for exercise and how often? ____________________________________________________________________ V. ENVIRONMENT A. WORK What kind of setting do you work in? Do you like your work? Any unusual problems with your work environment? Stress? Any history of work related injuries? Detail? ____________________________________________________________________ B. HOME House? Apt? How
long have you resided there? _________ Do you live near: Do you use an electric blanket or heating pad? C. ALLERGENS Do you own cats? Pets? Do you sleep with them? Home clean? Thoroughly vacuumed and or mopped at least once a week? VI. OTHER Use additional paper as necessary. This is the fun stuff. Now that you’ve worked so hard on completing this form, it’s time for some fun... Be as creative as you like. Draw a picture of yourself. (You can use a separate sheet of paper.) Mark where you hurt or have difficulties. Draw a picture of yourself as you would like to be in the future? If your illness or condition had a face, what would it look like? If it had a voice, what would it say? |
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