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new-patient-intake.html
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<!DOCTYPE html>
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<link rel="icon" type="image/x-icon" href="favicon.ico">
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Passion For Healing Naturopathic | Portland Oregon Mobile Naturopath Doctor</title>
<meta name="description" content="Portland Oregon Naturopathic Doctor, licensed N.D. House Calls" />
<meta name="keywords" content="portland, oregon, doctor, naturopath, naturopathic, licensed, ND, housecalls, mobile, home, healing, health, wellness, professional, herbs, treatment, general, praticioner, holistic, wholistic, affordable, inexpensive, cheap, low cost" />
<meta name="coverage" content="Worldwide" />
<meta name="distribution" content="Global" />
<meta name="rating" content="General" />
<meta name="revisit-after" content="30 days" />
<meta name="designer" content="E. Curtis Designs" />
<meta name="developer" content="Dan Johnson" />
<meta name="copyright" content="copyright 2010" />
<meta name="robots" content="index, follow" />
<meta http-equiv="imagetoolbar" content="no" />
<link href="css/reset.css" type="text/css" rel="stylesheet" media="screen" />
<link href="css/style.css" type="text/css" rel="stylesheet" media="screen" />
<link rel="shortcut icon" type="image/png" href="/favicon.png"/>
<script src="js/jquery.1.3.2-min.js" type="text/javascript"></script>
<script src="js/custom.js" type="text/javascript"></script>
<link rel="stylesheet" href="http://code.jquery.com/ui/1.11.2/themes/humanity/jquery-ui.css">
<script src="http://code.jquery.com/jquery-1.10.2.js"></script>
<script src="http://code.jquery.com/ui/1.11.2/jquery-ui.js"></script>
<meta charset="UTF-8">
<style type="text/css">
.ui-progressbar {
position: relative;
}
.progress-label, .progress-label1, .progress-label2 {
position: absolute;
left: 50%;
top: 4px;
font-weight: bold;
text-shadow: 1px 1px 0 #fff;
}
</style>
</head>
<body id="outer">
<script>
$(function() {
$( "#best_energy" ).selectmenu();
$( "#worst_energy" ).selectmenu();
$( "#progressbar1" ).progressbar({
value: parseInt((1 / 7) * 100)
});
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value: parseInt((2 / 7) * 100)
});
var progressbar = $( "#progressbar1" ), progressLabel = $( ".progress-label1" );
progressLabel.text( progressbar.progressbar( "value" ) + "%" );
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progressLabel.text( progressbar.progressbar( "value" ) + "%" );
});
</script>
<div id="page">
<div id="wrap">
<div id="header">
<h1 id="logo2"><a href="index.html">Passion for Healing Naturopathic</a></h1>
<ul id="main-nav">
<li><a href="index.html">About</a></li>
<li><a href="services.html">Services</a></li>
<li><a href="testimonials.html" class="current">Testimonials</a></li>
<li><a href="consultations.html">Consultation</a></li>
<li><a href="resources.html">Resources</a></li>
<!-- <li><a href="http://www.passionforhealingnaturopathic.com/blog" target="_blank">Blog</a></li> -->
<li><a href="contact.html">Contact</a></li>
</ul>
</div>
<!--end header-->
<div id="main-content">
<div id="wide-content">
<h3>Passion for Healing New Patient Intake Form</h3>
<p>This form is a detailed questionnaire designed to help you communicate your medical history, family risk factors, current and other health complaints, allergies, prescription/supplements list, and more, enabling Dr. Curry rapid understanding of your personal health needs. Successful health care and preventive medicine are only possible when the physician has a complete understanding of the patient physically, mentally and emotionally. Ultimately it will help her serve you and make your Naturopathic House Call more productive. You can download and print one from this website or Dr Curry can send you a paper version by mail. Please have it filled out and ready for review during your first visit. You may also want to prepare your own list of any additional questions or concerns that you have for Dr. Curry. If you are unable to fill out this form, Dr Curry can assist you on the first visit.</p>
<form id="intake" class="intake-form-field" action="contact.php" method="post">
<table>
<tr>
<td colspan="2" width="50%">First Name: <input type="text" name="first_name" id="first_name" value="" placeholder="First Name" required="true" style="width: 250px" /></td>
<td colspan="2" width="50%">Last Name: <input type="text" name="last_name" id="last_name" value="" placeholder="Last Name" required="true" style="width: 250px"/></td>
</tr>
<tr>
<td colspan="4">What are your expectations from this first Naturopathic visit?<br />
<textarea name="visit_expectations" id="visit_expectations" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
</tr>
<tr>
<td colspan="4">What expectations do you have of me personally as your physician?<br />
<textarea name="doctor_expectations" id="doctor_expectations" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
<tr>
<td colspan="4">What do you know about our approach?<br />
<textarea name="approach" id="approach" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
<tr>
<td colspan="4">Are there any potential obstacles you foresee in addressing unhealthy lifestyle factors Naturopathically?<br />
<textarea name="obstacles" id="obstacles" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
<tr>
<td colspan="4">Are you currently receiving healthcare?
<input type="radio" name="receiving_healthcare" value="yes"> Yes <input type="radio" name="receiving_healthcare" value="no"> No</td>
</tr>
<tr>
<td colspan="4">If yes, where and from whom?<br>
<input type="text" name="current_doctor" id="current_doctor" value="" class="intake-wide"/>
</tr>
<tr>
<td colspan="4">If no, when, where and for what reason did you last receive medical or health care?
<input type="text" name="last_doctor" id="last_doctor" value="" class="intake-wide"/>
</tr>
<tr>
<td colspan="4">In order of importance please list your most important health problems:<br />
1. <input type="text" name="problem_1" id="problem_1" value="" style="width: 96%"/><br />
2. <input type="text" name="problem_2" id="problem_2" value="" style="width: 96%"/><br />
3. <input type="text" name="problem_3" id="problem_3" value="" style="width: 96%"/><br />
4. <input type="text" name="problem_4" id="problem_4" value="" style="width: 96%"/><br />
</tr>
<tr><td valign="center" height="40px" colspan="4" class="progress"><div id="progressbar1"><div class="progress-label1"></div></td></tr>
<tr>
<td colspan="4">Please list any contagious diseases you may have at this time:<br />
<textarea name="contagious_diseases" id="contagious_diseases" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
<tr>
<td colspan="4">Any major traumas, accidents, broken bones?<br />
<textarea name="traumas_accidents_broken_bones" id="traumas_accidents_broken_bones" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
<tr>
<td colspan="4">Any other health complaints not listed?<br />
<textarea name="health_complaints" id="health_complaints" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
<td colspan="4">
<strong>Hospitalization, Surgery, Imaging</strong> Please list dates of any hospitalizations, surgeries, procedures, X‐Rays, CAT Scans, MRIs, Bone density scans, EEG, EKG’s or other imaging that have you had:<br />
<textarea name="health_complaints" id="health_complaints" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
</tr>
<td colspan="4">Allergies or Hypersensitivities</td>
</td>
<tr>
<td width="30%">Any drugs?</td><td colspan="3"><input type="text" name="last_doctor" id="last_doctor" value="" class="intake-wide"/></td></tr>
<tr>
<td width="30%">Any foods?<td colspan="3"><input type="text" name="last_doctor" id="last_doctor" value="" class="intake-wide"/></td></tr>
<tr>
<td width="30%">Any environmental or chemicals?<td colspan="3"><input type="text" name="last_doctor" id="last_doctor" value="" class="intake-wide"/></td></tr>
<tr>
<td colspan="4">Current Medications. Please check any you take:</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Pain relievers</td><td><input type="checkbox" name="" id="">Antacids</td><td><input type="checkbox" name="" id="">Cortisone</td><td><input type="checkbox" name="" id="">Antibiotics</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Tranquilizers</td>
<td><input type="checkbox" name="" id="">Thyroid medication</td>
<td><input type="checkbox" name="" id="">Sleeping pills</td>
<td><input type="checkbox" name="" id="">Laxatives</td>
<tr>
<td><input type="checkbox" name="" id="">Appetite suppressants</td>
<td><input type="checkbox" name="" id="">Inhalers</td>
<td><input type="checkbox" name="" id="">Allergy pills</td>
</tr>
<td colspan="4">Please list all prescription medications and over‐the‐counter medications you take<br />
<textarea name="medications" id="medications" rows="3" class="intake-form-field intake-wide"></textarea></td>
<tr>
<td colspan="4"><strong>Supplements</strong> Please list any vitamins or other supplements you take:<br />
<textarea name="supplements" id="supplements" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
<td colspan="4"><strong>Family History</strong> Do you have a family history of any of the following (please circle)?</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Diabetes</td>
<td><input type="checkbox" name="" id="">Heart Disease </td>
<td><input type="checkbox" name="" id="">High Blood Pressure</td>
<td><input type="checkbox" name="" id="">Kidney Disease</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Epilepsy</td>
<td><input type="checkbox" name="" id="">Arthritis</td>
<td><input type="checkbox" name="" id="">Glaucoma</td>
<td><input type="checkbox" name="" id="">Tuberculosis</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Stroke</td>
<td><input type="checkbox" name="" id="">Anemia</td>
<td><input type="checkbox" name="" id="">Mental Illness</td>
<td><input type="checkbox" name="" id="">Cancer</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Allergies/Hay fever/Hives</td>
<td><input type="checkbox" name="" id="">Asthma</td>
<td><input type="checkbox" name="" id="">Sickle cell anemia</td>
<td><input type="checkbox" name="" id="">Hemachromatosis</td>
</tr>
</tr>
<td colspan="4">Any other relevant family history?<br />
<textarea name="family_history" id="family_history" rows="3" class="intake-form-field intake-wide"></textarea></td>
</tr>
</tr>
<tr><td valign="center" height="40px" colspan="4" class="progress"><div id="progressbar2"><div class="progress-label2"></div></td></tr>
<tr>
<td colspan="4">Childhood Illnesses Please circle whether you had any of these as a child:</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Scarlet fever</td>
<td><input type="checkbox" name="" id="">Diphtheria</td>
<td><input type="checkbox" name="" id="">Rheumatic fever</td>
<td><input type="checkbox" name="" id="">Mumps</td>
</tr>
<tr>
<td><input type="checkbox" name="" id="">Measles</td>
<td><input type="checkbox" name="" id="">German measles</td>
</tr>
<tr>
<td colspan="4">Other: <input type="text" name="" id="" class="intake-wide"></td>
</tr>
<tr>
<td colspan="4"><strong>General Information:</strong></td></tr>
<tr>
<td colspan="4">Height: <input type="number" name="" id="">
Weight (lbs): <input type="number" name="" id="">
Unexplained weight gain/loss? <input type="radio" name="unexplained_weight" value="yes"> Yes <input type="radio" name="unexplained_weight" value="no"> No</td>
</tr>
<tr>
<td colspan="4">Maximum Weight: <input type="number" name="" id="">
When: <input type="date" name="" id=""> Desired Weight: <input type="number" name="" id="">
</tr>
<tr>
<td colspan="2">When during the day is your energy: </td>
<td>
Best?
<select name="best_energy" id="best_energy">
<option value="Morning">Morning</option>
<option value="Noon">Noon</option>
<option value="Night">Night</option>
</select>
</td>
<td>
Worst?
<select name="worst_energy" id="worst_energy">
<option value="Morning">Morning</option>
<option value="Noon">Noon</option>
<option value="Night">Night</option>
</select></td>
</tr>
<tr>
<td colspan="4"><strong>Typical Food Intake</strong> Please describe a typical days worth of meals and snacks:</td>
</tr>
<tr><td>Breakfast:</td><td colspan="3"> <input type="text" name="" id="" style="width: 600px"></td></tr>
<tr><td>Lunch:</td><td colspan="3"> <input type="text" name="" id="" style="width: 600px"></td></tr>
<tr><td>Dinner:</td><td colspan="3"> <input type="text" name="" id="" style="width: 600px"></td></tr>
<tr><td>Snacks:</td><td colspan="3"> <input type="text" name="" id="" style="width: 600px"></td></tr>
<tr><td>Deserts/Candy:</td><td colspan="3"> <input type="text" name="" id="" style="width: 600px"></td></tr>
<tr><td colspan="4">Water (cups): <input type="number" name="" id="" style="width: 50px"> Soda/juices/energy drinks: <input type="number" name="" id="" style="width: 50px"> Coffee/tea: <input type="number" name="" id="" style="width: 50px"></td></tr>
<tr>
<td colspan="2">
Do you eat three meals a day?
<input type="radio" name="three_meals" value="yes"> Yes
<input type="radio" name="three_meals" value="no"> No
</td>
<td colspan="2">
Do you go on diets often?
<input type="radio" name="diet_often" value="yes"> Yes
<input type="radio" name="diet_often" value="no"> No
</td>
</tr>
<tr>
<td colspan="4">
Do you eat out often?
<input type="radio" name="eat_out" value="yes"> Yes
<input type="radio" name="eat_out" value="no"> No
If yes how often? <input type="text" name="" id="">
</td>
</tr>
<tr>
<td colspan="4">
Do you eat refined sugars?
<input type="radio" name="eat_out" value="yes"> Yes
<input type="radio" name="eat_out" value="no"> No
Do you add salt?
<input type="radio" name="eat_out" value="yes"> Yes
<input type="radio" name="eat_out" value="no"> No
Fried foods regularly?
<input type="radio" name="eat_out" value="yes"> Yes
<input type="radio" name="eat_out" value="no"> No
</td>
</tr>
<tr><td colspan="4"><strong>Habits</strong></td></tr>
<tr>
<td colspan="4">Main interests and hobbies:<br />
<textarea name="health_complaints" id="health_complaints" rows="3" class="intake-form-field intake-wide"></textarea>
</td>
</tr>
<tr>
<td colspan="4">
Enjoy your work?
<input type="radio" name="enjoy_work" value="yes"> Yes
<input type="radio" name="enjoy_work" value="no"> No
Take vacations?
<input type="radio" name="take_vacation" value="yes"> Yes
<input type="radio" name="take_vacation" value="no"> No
Spend time outside?
<input type="radio" name="spend_time_outside" value="yes"> Yes
<input type="radio" name="spend_time_outside" value="no"> No
</td>
</tr>
<td colspan="4">
Do you have a religious or spiritual practice?
<input type="radio" name="religion" value="yes"> Yes
<input type="radio" name="religion" value="no"> No
If yes, what?
<input type="text" name="religion_type" value="yes">
</td>
</tr>
</table>
</form>
</div>
<!--end content-->
</div>
<!--end main_content-->
<div id="footer"><script type="text/javascript">$('#footer').load('footer.html');</script></div>
</div>
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