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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  




Medical History

Name *
 Date of Birth (mm/dd/yyyy) *
 Today's Date *
Previous Hospitalizations/Surgeries/Serious Illnesses *
Include:  When, Hospital, City, State
Medications *
Please list name, dose, frequency (Include nonprescription)
Patient Social History:
Marital Status:
Single   Married   Separated   Divorced   Widowed  
Use of alcohol:
Never   Rarely   Moderate   Daily  
Use of tobacco:
Never   Previously, but quit   Current  
Use of drugs:
"Never" or Type/Frequency
Excessive exposure to:
(at home or at work)
Fumes   Dust   Solvents   Air-borne Particles   Noise  

Family Medical History: Please include:  Age, any known diseases & if deceased, cause of death

Father
 Mother
 Spouse
Siblings:
 Children:

Past Medical History: 
Have you ever had the following, check "yes" or "no", leave blank if uncertain-

Measles
Yes   No  
Rheumatic Fever
Yes   No  
Cancer
Yes   No  
Asthma
Yes   No  
Kidney Disease
Yes   No  
Mumps
Yes   No  
Arthritis
Yes   No  
Polio
Yes   No  
Hives or Eczema
Yes   No  
Thyroid Disease
Yes   No  
Chickenpox
Yes   No  
Venereal Disease
Yes   No  
Glaucoma
Yes   No  
AIDS or HIV+
Yes   No  
Heart Disease
Yes   No  
Whooping Cough
Yes   No  
Anemia
Yes   No  
Hernia
Yes   No  
Infectious Mono
Yes   No  
Diabetes
Yes   No  
Scarlet Fever
Yes   No  
Bladder Infections
Yes   No  
Blood or Plasma
Transfusions
Yes   No  
Bronchitis
Yes   No  
Hemorrhoids
Yes   No  
Diphtheria
Yes   No  
Epilepsy
Yes   No  
Back trouble
Yes   No  
Mitral Valve Prolapse
Yes   No  
Ulcer
Yes   No  
Smallpox
Yes   No  
Migrane Headaches
Yes   No  
High Blood Pressure
Yes   No  
Stroke
Yes   No  
Bleeding Tendency
Yes   No  
Pneumonia
Yes   No  
Tuberculosis
Yes   No  
Low Blood Pressure
Yes   No  
Hepatitis
Yes   No  
Other history of disease:
(please list)
 Date of last chest x-ray
(mm/dd/yyyy)

Review of Systems:  Do you have a history of the following?
Check box if yes
Constitutional Symptoms
Good general health lately  
Recent weight change  
Fever  
Fatigue  
Headaches  
Cardiovascular
Heart trouble  
Chest pain or angina pectoris  
Palpitation  
Shortness of breath  
Swelling of feet, ankles or hands  
Endocrine
Glandular or hormone problem  
Excessive thrist or urination  
Heat or cold intolerance  
Skin becoming dryer  
Change in hat or glove size  
Eyes
Eye disease or injury  
Wear glasses/contact lenses  
Blurred or double vision  
Psychiatric
Memory loss or confusion  
Nervousness  
Depression  
Insomnia  
Respiratory
Chronic or frequent coughs  
Spitting up blood  
Shortness of breath  
Wheezing  
Hematologic/Lymphatic
Slow to heal after cuts  
Bleeding or bruising tendency  
Anemia  
Phlebitis  
Past transfusion  
Enlarged gonads  
Neurological
Frequent or recurring headaches  
Light headed or dizzy  
Convulsions or seizures  
Numbness or tingling sensations  
Tremors  
Paralysis  
Head Injury  
Integumentary (skin, breast)
Rash or itching  
Change in skin color  
Change in hair or nails  
Varicose veins  
Breast pain  
Breast lump  
Breast discharge  
Ears/Nose/Mouth/Throat
Hearing loss or ringing  
Earaches or drainage  
Chronic sinus problem or rhinitis  
Nose bleeds  
Mouth sores  
Bleeding gums  
Bad breath or bad taste  
Sore throat or voice change  
Swollen glands in neck  
Gastrointestinal
Loss of appetite  
Change in bowel movements  
Nausea or vomiting  
Frequent diarrhea  
Painful bowel movements  
Constipation  
Rectal bleeding/blood in stool  
Abdominal pain  
Musculoskeletal
Joint pain  
Joint stiffness or swelling  
Weakness of muscles or joints  
Muscle pain or cramps  
Back pain  
Cold extremities  
Difficulty in walking  
Allergic/Immunologic
History of allergy or reaction to:
Penicillin or other antibiotics  
Morphine, Demerol, or other narcotics  
Novocain or other anesthetics  
Aspirin or other pain remedies  
Tetanus antitoxin or other serums  
Iodine, Merthiolate or other antiseptic  
Other drugs/medications  
Genitourinary
Frequent urination  
Burning or painful urination  
Blood in urine  
Change inforce/strain of urination  
Incontinence or dribbling  
Kidney stones  
Sexual difficulty  
Genitourinary (cont.)
(male/female)
Male- testicle pain  
Female- irregular periods  
Female- pain with periods  
Female- vaginal discharge  
Please list any other known drug allergies or
reactions:
 Female- # of pregnancies
 Female- # of miscarriages
 Female- date of last pap smear
*** To the best of my knowledge, the questions on this form have been accurately answered.  I understand that providing incorrect information can be dangerous to my health.  It is my responsibility to inform the doctor's office of any changes in my medical status.  I also authorize the healthcare staff to perform the necessary services I may need.
Signature of Patient, Parent or Guardian
to be signed upon first office visit
 Date
Signature Date

* Required to submit this form


















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