2 N.W. 3^rd Avenue

Portland, Oregon 97209

PATIENT HEALTH

HISTORY

Patient’s Name: ___________________________________________________________________________

First Middle Last

Natural medicine healthcare is possible only when the physician or practitioner completely understands the patient’s physical, mental, and emotional conditions. The information you provide helps your practitioner understand your needs and how to help you reach your health goals. Please write legibly and answer all questions thoroughly. Feel free to mark anything you may have a question about.

Address: _________________________________________________________________________________________

City: _______________________________________ State: __________________________ Zip code: _____________

Telephone numbers: home ______________________________ cell __________________________________

What phone number should we use for your appointment reminder call and for clinic correspondence? _________________________________

SS #: ___________________________ Driver’s license #: _____________________ Birth date: __________________

Age: ____________ Gender (circle one): M F Other Please specify race:___________________ Number of children you have: ________

Employer: _____________________________ Employers Address: ________________________

Occupation: _________________________________ Hours per week:________

Work phone number: ___________________________ Ext: _____ Gross Monthly Household Income:_________

Marital status: ð Single ð Married ð Partnership ð Separated ð Divorced

Housing Status: _______________________________

Emergency contact: ________________________________________________________________________________

Relationship: ________________________________ Telephone number: ___________________________________

If someone other than patient is responsible for payment, please complete the following:

Name of responsible party: _______________________________________ SS#: ______________________________

Relationship to patient: __________________________________________ Phone #: __________________________

Employer & address: _______________________________________________________________________________

I acknowledge that I am financially responsible for all charges. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize Mercy & Wisdom Healing Center to release information necessary to secure payment.

Signature: ___________________________________________________ Date: ________________________________

What are your most important health concerns?_______________________________________________________

__________________________________________________________________________________________________

When did you last visit a doctor’s office, medical clinic, or hospital? Please explain. _______________________

__________________________________________________________________________________________________

How did you hear about our clinic? __________________________________________________________________

Are you aware of any allergies to food, drugs, or other environmental allergens (cats, mold, and dust)? If yes, please list and explain: _____________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

Self and Family History

What hospitalizations or surgeries have you had? _____________________________________________________

_________________________________________________________________________________________________

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What diagnostic imaging studies have you had? ð Bone density scan ð Mammogram

ð Electrocardiogram ð Electroencephalogram ð X-rays ð CT scan ð MRI

Medications and/or Supplements

Do you take or use any of the following?

ð Pain relievers (aspirin, ibuprofen)

ð Diet pills, appetite suppressants

ð Cortisone (cream or pills)

ð Thyroid medication

ð Antacids

ð Laxatives

ð Tranquilizers

ð Antibiotics

ð Sleeping pills

Please list any prescription medications, over-the-counter medications, vitamins, or other supplements you are taking: _______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

General

Height: ___________________ Weight: ________________lbs. Weight one year ago: _____________lbs.

Maximum weight: __________________lbs. When? _________________________________________________

When during the day is your energy best? ________________________ Worst? __________________________

Family History

Do you have a family history of any of the following (please circle)?

Anemia Diabetes Heart disease Respiratory disease

Arthritis Epilepsy High blood pressure Stroke

Asthma Gall Bladder disease Kidney disease Thyroid problems

Cancer Glaucoma Liver disease Tuberculosis

Cataracts Hay fever/hives Mental illness

Is your father still living? Yes; his age ____ No; age at time of death _____ Cause of death _______________

Is your mother still living? Yes; her age ____ No: age at time of death _____ Cause of death _______________

Childhood Illnesses

Please circle whether you have/had any of the following conditions as a child/adolescent:

Diphtheria Mumps

German measles Rheumatic fever

Measles Scarlet fever

Other _______________________

Past Immunizations

Please circle any of the following immunizations you have had. If unsure, please write a question mark beside the immunization.

Diptheria Polio

Measles/Mumps/Rubella (MMR) Tetanus

Pertussis Other ________________________

Review of Systems

Please circle. Y= Yes, present condition. N=No, never had the condition. P=Problem of the past.

Head

Headaches Y P N Migraine headaches Y P N

Head injury Y P N Jaw/TMJ problems Y P N

Ears

Ringing Y P N Dizziness Y P N

Earaches Y P N Impaired hearing Y P N

Neck

Lumps Y P N Swollen glands Y P N

Goiter Y P N Pain or stiffness Y P N

Skin

Rashes Y P N Psoriasis Y P N Eczema, hives Y P N

Lumps Y P N Acne, boils Y P N Color changes Y P N

Itching Y P N Loss of hair Y P N Night sweats Y P N

Musculoskeletal

Joint pain Y P N Muscle spasms Y P N Weakness Y P N

Arthritis Y P N Broken bones Y P N Sciatica Y P N

Eyes

Blurred vision Y P N Cataracts Y P N Glasses/contacts Y P N

Eye pain/strain Y P N Glaucoma Y P N Tearing/dryness Y P N

Spots in eyes Y P N Color blind Y P N Double vision Y P N

Review of Systems

Please circle. Y= Yes, present condition. N=No, never had the condition. P=Problem of the past.

Nose/Sinuses

Stuffiness Y P N Loss of smell Y P N Sinus problems Y P N

Hayfever Y P N Nose bleeds Y P N Frequent colds Y P N

Mouth/Throat

Hoarseness Y P N Gum problems Y P N Freq. sore throat Y P N

Jaw clicks Y P N Dental cavities Y P N Sore lips/tongue Y P N

Respiratory

Asthma Y P N Wheezing Y P N Spitting up blood Y P N

Cough Y P N Bronchitis Y P N Difficulty breathing Y P N

Sputum Y P N Pneumonia Y P N Pain with breathing Y P N

Pleurisy Y P N Emphysema Y P N Shortness of breath Y P N

Tuberculosis Y P N at night Y P N

lying down Y P N

Cardiovascular

Angina Y P N Chest pain Y P N Blood clots Y P N

Murmur Y P N Heart disease Y P N Rheumatic fever Y P N

Fainting Y P N Ankle swelling Y P N Low/high blood Y P N

pressure

Gastrointestinal

Diarrhea Y P N Constipation Y P N Changes in thirst Y P N

Ulcers Y P N Black stool Y P N Coughing up blood Y P N

Jaundice Y P N Hemorroides Y P N Gall bladder disease Y P N

Heartburn Y P N Abdominal pain Y P N Blood in stool Y P N

Liver disease Y P N How many bowel movements per day? ___________

Urinary

Incontinence Y P N Frequent infections Y P N Painful urination Y P N

Kidney stones Y P N Frequency at night Y P N

Blood/Peripheral Vascular

Anemia Y P N Cold hands/feet Y P N Thrombophlebitis Y P N

Leg pain Y P N Easy bruising Y P N Varicose veins Y P N

Neurological

Fainting Y P N Paralysis Y P N Numbness/tingling Y P N

Seizures Y P N Loss of memory Y P N Muscle weakness Y P N

Emotional

Mood swings Y P N Nervousness Y P N Tension/stressed Y P N

Anxiety Y P N Depression Y P N

Endocrine

Hypothyroid Y P N Excessive thirst Y P N Cold intolerance Y P N

Hyperthyroid Y P N Excessive hunger Y P N Heat intolerance Y P N

Male Reproductive

Hernias Y P N Testicular masses Y P N Discharge or sores Y P N

Prostate issues Y P N Sexual difficulty Y P N Testicular pain Y P N

Venereal Y P N Premature ejaculation Y P N

disease

Female Reproductive

Age of first menses _________________________ Age of last menses (if menopausal) __________________

Length of cycle _____________________________ Duration of menses _______________________________

Date of last annual exam _____________________

Painful menses Y P N Endometriosis Y P N Ovarian cysts Y P N

Heavy flow Y P N Fertility issues Y P N Cervical dysplasia Y P N

Breasts tender Y P N Venereal disease Y P N Bleeding between cycles Y P N

Sexually active Y P N Cycles regular Y P N Menopausal symptoms Y P N

Sexual difficulty Y P N Abnormal pap Y P N PMS Y P N

Breast lump(s) Y P N Nipple discharge Y P N Do self breast exams Y P N

Birth control Y P N If yes, what type?_____________________________________________________

Number of pregnancies _______________________ Number of live births ____________________________

Number of miscarriages _______________________ Number of abortions ____________________________

Is there anything else you would like us know in order to serve you better?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Consent for Treatment:

I understand that my care as a patient at MWHC is directed by supervising staff physicians, licensed acupuncturists, and/or other licensed professionals. I consent to services rendered and provided to me under the instructions of these professionals assisting in my care, as well as volunteer staff physicians who may be associated for the purpose of consulting.

I recognize that MWHC is a teaching institution. I agree that persons who are students and resident physicians may participate in my care as part of the educational programs of the institution. I may be contacted by MWHC physicians for voluntary participation in clinical research projects. I do, however, have the right to refuse these programs without jeopardizing my future care at MWHC in any way.

I have fully read and understand the above agreements and authorizations.

_________________________________________________ ______________________________

Patient (18 years or older) Date

_________________________________________________ ______________________________

Parent, Guardian, Responsible Party Date

HIPAA Notice of Privacy Practices and Consent: I hereby consent to the use and disclosure of my protected health information by MWHC for the purposes of treatment, payment and healthcare operations, or as otherwise required by law.

· MWHC has posted their Notice of Privacy Practices which provides more detailed information about the usage and disclosure of my protected health information. I have a right to review the Notice prior to signing this consent and to receive a printed copy of the Notice.

· I have the right to request restrictions to the usage and disclosure of my protected health information.

· I have the right to request an alternative to the standard method of communication of my protected health information.

· I have the right to revoke this consent, in writing, at any time. Revocations will be honored as of the date they are received by MWHC at the following address:

2 NW 3^nd Avenue

Portland, Oregon 97209

· I understand that while MWHC may honor these requests, they are not required by law to do so.

· I am aware that MWHC reserves the right to change the terms of their Notice of Privacy Practices and to make new notice of Privacy Practices provisions effective for all protected health information that they maintain. In the event of amendments, MWHC will make available a revised Notice of Privacy Practice for my review.

Alternative method of communication request: As a courtesy, it is MWHC´s policy to call your home on the day prior to your scheduled appointment to remind you of your appointment time. We may leave a reminder message on your voice-mail or with a person answering the phone – no personal health information will be disclosed.

ð I agree with MWHC’s standard method of communication.

ð Please change as follows:

ð Please contact me at the following telephone number: ___________________________

ð I prefer not to receive reminder calls.

Statement of Financial Responsibility: I understand and agree to the following:

ð Payment for services rendered is my responsibility as the patient or patient’s responsible party.

ð I am responsible for paying for all services, including lab tests, rendered at the time of service. How will you be paying for your visit? Cash, checks (checks accepted with valid Drivers Lic., Addr. & Ph#).

ð If I am receiving a discount of any sort, I am responsible for providing accurate and thorough documentation supporting it and I am responsible for paying in full at the time of service.

Insurance billing: If I am billing insurance for services rendered, I understand and agree to the following:

ð I must submit invoices from MWHC to my insurance carrier for reimbursement

ð I authorize MWHC to release pertinent medical records related to billing. This release applies to support of the insurance billing process only.

ð I am responsible for any and all charges at time of services.

We require at least 24 hour advance notice for canceling appointments.

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Signature of patient or patient’s responsible party Date