Caution!

Visiting this web site requires a newer version of Netscape Communicator.

Visit Microsoft's Web site to obtain the newest version of Internet Explorer, or visit Netscape's Web site to obtain the newest version of Netscape Communicator.

Visiting this web site without first upgrading your browser may result in unreliable behavior.










Dr. Chris Booren, Naturopathic Physician



Home Page


Mission Statement
Naturopathic Services Offered
Naturopathic Services


Natural Therapeutics


About Dr. Chris


Optimal Health Center

Communications



Hours of Operation


Specials


Calendar of Events


FAQ/About Naturopathic Medicine


Links To Alternative Practioneers

Specialties



Acupressure
Allergies
Allergies
Birth Doula
Birth Doula


Cancer Treatments


Chronic Conditions


Detox Programs


I.V. Therapy
Pediatrics Naturally
Pediatrics

Forms



New Patient Information


Office Policies


Comfidentiality Agreement


Medical History


Current Health Assessment




  We're Easy to Find! (map)
Naturopathic Medicine

Optimal Health Center
1820 SW Vermont St. Suite G, Portland, OR 97219  
(503) 246-3919   

drchrisbooren@yahoo.com  




Current Health Assessment

 

Name *
 Date of Birth (mm/dd/yyyy) *
 Today's Date: *
Please list the 5 major health concerns in your order of importance: *
Cheif Complaint: *
History of Present Illness:
Location: *
Where is the pain/problem
Quality: *
Example: normal versus abnormal color, activity, etc.
Severity: *
How severe is the pain/problem on a scale of 1-5
with 5 being the most severe?
 Duration: *
How long have you had this pain/problem?, or, When did it start?
Timing: *
Does the pain/problem occur at a specific time?
 Context:
Where were you at the onset of this pain/problem?
Associated signs/symptoms *
What other associated problems have you been having?
 Modifying factors: *
What makes the pain/problem worse or better?, or, Have you had previous episodes?
Please select the appropriate number "0-3" on all questions below as related to your CURRENT health assessment:

"0" as the least/never
"3" as the most/always

Category I: Category IX :
Feeling that bowels do not empty completely *
0   1   2   3  
Cannot fall asleep *
0   1   2   3  
Lower abdominal pain relief by passing stool or gas *
0   1   2   3  
Perspire easily *
0   1   2   3  
Alternating constipation and diarrhea *
0   1   2   3  
Under high amounts of stress *
0   1   2   3  
Diarrhea *
0   1   2   3  
Weight gain when under stress *
0   1   2   3  
Constipation *
0   1   2   3  
Wake up tired even after 6 or more hours of sleep *
0   1   2   3  
Hard, dry, or small stool *
0   1   2   3  
Excessive perspiration *
or perspiration with little or no activity
0   1   2   3  
Coated tongue of "fuzzy" debris on tongue *
0   1   2   3  
Pass large amount of foul smelling gas *
0   1   2   3  
Category X :
More than 3 bowel movements daily *
0   1   2   3  
Tired, sluggish *
0   1   2   3  
Use laxatives frequently *
0   1   2   3  
Feel cold- hands, feet, all over *
0   1   2   3  
Require excessive amounts of sleep *
to function properly
0   1   2   3  
Category II: Increase in weight gain *
even with a low-calorie diet
0   1   2   3  
Excessive belching, burping, or bloating
0   1   2   3  
Gain weight easily *
0   1   2   3  
Gas immediately following a meal *
0   1   2   3  
Difficult, infrequent bowel movements *
0   1   2   3  
Offensive breath *
0   1   2   3  
Depression, lack of motivation *
0   1   2   3  
Difficult bowel movements *
0   1   2   3  
Morning headaches that wear off as the day progresses *
0   1   2   3  
Sense of fullness during/after meals
0   1   2   3  
Outer third of eyebrow thins *
0   1   2   3  
Difficulty digesting fruits/vegetables: *
undigested foods found in stools
0   1   2   3  
Thinning of hair on scalp, face or genitals
or excessive falling hair
0   1   2   3  
Dryness of skin and/or scalp *
0   1   2   3  
Category III : Mental Sluggishness *
0   1   2   3  
Stomach pain, burning or aching *
(1-4 hrs after eating)
0   1   2   3  
Do you frequently use antacids? *
0   1   2   3  
Category XI :
Feeling hungry an hour or two after eating *
0   1   2   3  
Heart palpitations *
0   1   2   3  
Heartburn *
when lying down or bending forward
0   1   2   3  
Inward trembling *
0   1   2   3  
Temporary heartburn relief from: *
antacids, food, milk, carbonated beverages
0   1   2   3  
Increased pulse even at rest *
0   1   2   3  
Digestive problems subside with rest and relaxation *
0   1   2   3  
Nervous and emotional *
0   1   2   3  
Heartburn due to spicy foods *
chocolate, citrus, peppers, alcohol + caffeine
0   1   2   3  
Insomnia *
0   1   2   3  
Difficulty gaining weight *
0   1   2   3  
Category IV :
Roughage and fiber cause constipation *
0   1   2   3  
Category XII :
Indigestion and fullness lasts *
2-4 hrs after eating
0   1   2   3  
Diminished sex drive *
0   1   2   3  
Pain, tenderness and soreness *
on left side under rib cage
0   1   2   3  
Menstrual disorders *
or lack of menstruation
0   1   2   3  
Excessive passage of gas *
0   1   2   3  
Increased ability to eat sugars without symptoms *
0   1   2   3  
Nausea and/or vomiting *
0   1   2   3  
Stool undigested, foul smelling *
mucous-like, greasy, or poorly formed
0   1   2   3  
Category XIII :
Frequent urination *
0   1   2   3  
Increased sex drive *
0   1   2   3  
Increased thirst and appetite *
0   1   2   3  
Tolerance to sugars reduced *
0   1   2   3  
Difficulty losing weight *
0   1   2   3  
"Splitting" type headaches *
0   1   2   3  
Category V : Category XIV :  (Males only)
Greasy or high fat foods cause distress *
0   1   2   3  
Urination difficulty or dribbling
0   1   2   3  
Lower bowel gas and/or bloating *
several hours after eating
0   1   2   3  
Urination frequent
0   1   2   3  
Bitter metallic taste in mouth *
especially in the morning
0   1   2   3  
Pain inside of legs or heels
0   1   2   3  
Unexplained itchy skin *
0   1   2   3  
Feeling of incomplete bowel evacuation
0   1   2   3  
Yellowish cast to eyes *
0   1   2   3  
Leg nervousness at night
0   1   2   3  
Stool color alternates *
from clay colored to normal brown
0   1   2   3  
Reddened skin, especially palms *
0   1   2   3  
Category XV :  (Males only)
Dry or flaky skin and/or hair *
0   1   2   3  
Decrease in libido
0   1   2   3  
History of gallbladder attacks or stones *
0   1   2   3  
Decrease in spontaneous morning erections
0   1   2   3  
Have you had your gallbladder removed? *
yes   no  
Decrease in fullness of erections
0   1   2   3  
Difficulty in maintaining morning erections
0   1   2   3  
Category VI : Spells of mental fatigue
0   1   2   3  
Crave sweets during the day *
0   1   2   3  
Inability to concentrate
0   1   2   3  
Irritable if meals are missed *
0   1   2   3  
Episodes of depression
0   1   2   3  
Depend on coffee to keep yourself *
going or get started
0   1   2   3  
Muscle soreness
0   1   2   3  
Get lightheaded if meals are missed *
0   1   2   3  
Decrease in physical stamina
0   1   2   3  
Eating relieves fatigue *
0   1   2   3  
Unexplained weight gain
0   1   2   3  
Feel shaky, jittery, tremors *
0   1   2   3  
Increase in fat distribution
around chest and hips
0   1   2   3  
Agitated, easily upset, nervous *
0   1   2   3  
Sweating attacks
0   1   2   3  
Poor memory, forgetful *
0   1   2   3  
More emotional than in the past
0   1   2   3  
Blurred vision *
0   1   2   3  
Category XVI :  (Menstruating Females Only)
Category VII : Are you perimenopausal
Yes   No  
Fatigue after meals *
0   1   2   3  
Alternating menstrual cycle lengths
Yes   No  
Crave sweets during the day *
0   1   2   3  
Extended menstrual cycle
greater than 32 days
Yes   No  
Eating sweets does not relieve cravings for sugar *
0   1   2   3  
Shortened menses
less than every 24 days
Yes   No  
Must have sweets after meals *
0   1   2   3  
Pain and cramping during periods
0   1   2   3  
Waist girth is equal or larger than hip girth *
0   1   2   3  
Scanty blood flow
0   1   2   3  
Frequent urination *
0   1   2   3  
Heavy blood flow
0   1   2   3  
Increased thirst & appetite *
0   1   2   3  
Breast pain and swelling during menses
0   1   2   3  
Difficulty losing weight *
0   1   2   3  
Pelvic pain during menses
0   1   2   3  
Irritable and depressed during menses
0   1   2   3  
Category VIII : Acne break-outs
0   1   2   3  
Cannot stay asleep *
0   1   2   3  
Facial hair growth
0   1   2   3  
Crave salt *
0   1   2   3  
Hair loss/thinning
0   1   2   3  
Slow starter in the morning *
0   1   2   3  
Dizziness when standing up quickly *
0   1   2   3  
Category XVII :  (Menopausal Females Only)
Afternoon headaches *
0   1   2   3  
How many years have you been menopausal
Headaches with exertion or stress *
0   1   2   3  
Since menopause, do you ever have uterine bleeding
Yes   No  
Weak nails *
0   1   2   3  
Hot flashes
0   1   2   3  
Mental fogginess
0   1   2   3  
Please fill in an answer for the following: Disinterest in sex
0   1   2   3  
How many alcohol beverages
do you comsume per week
 Mood swings
0   1   2   3  
How many caffeinated beverages *
do you consume per day
 Depression
0   1   2   3  
How many times do you eat out per week *
 Painful intercourse
0   1   2   3  
How many times a week do you eat fish *
 Shrinking breasts
0   1   2   3  
How many times a week *
do you eat raw nuts or seeds
Facial hair growth
0   1   2   3  
How many times a week do you workout *
 Acne
0   1   2   3  
Do you smoke *
If yes, how many times a day
 Increased vaginal pain, dryness or itching
0   1   2   3  
List the three worst foods you eat during the average week: *
List the three healthiest foods you eat during the average week: *
Rate your stress levels on a scale of 1-10 during the average week: *

* Required to submit this form



Click here to see current results.















Sign In
 Sign In