Washington
Homeopathic
Clinic
Michael Baker, ND, MS, DHANP
Stephanie Pleiman, ND
Ryan Robbins, ND
2025 112th Ave NE
Building 2, Suite 300
Bellevue, WA 98004
(425) 881-8929
www.wahomeopathy.com
Name Date Birth date
Date of last physical exam What is your reason for today’s visit?
Symptoms check (P) symptoms you currently have or have had in the past year.
Washington
Homeopathic
Clinic
General
q Chills
q Depression
q Dizziness
q Fainting
q Fever
q Forgetfulness
q Headache
q Loss of sleep
q Loss of weight
q Nervousness or anxiety
q Numbness
q Sweats
Muscle/Joint/Bone
Pain, weakness or numbness in:
q Arms Hips
q Hands Feet
q Back Legs
q Neck Shoulders
Genito-urinary
q Blood in urine
q Frequent urination
q Lack of bladder control
q Painful urination
Gastrointestinal
q Appetitive poor
q Bowel changes
q Constipation
q Diarrhea
q Excessive hunger
q Excessive thirst
q Gas
q Hemorrhoids
q Indigestion
q Nausea
q Rectal bleeding
q Stomach pain
q Vomiting
q Vomiting blood
Cardiovascular
q Chest pain
q High blood pressure
q Irregular heart beat
q Low blood pressure
q Poor circulation
q Rapid heart beat
q Swelling of ankles
q Varicose veins
Eye, Ear, Nose, Throat
q Bleeding gums
q Blurred vision
q Cold sores
q Crossed eyes
q Difficulty swallowing
q Double vision
q Earache
q Ear Discharge
q Hay fever
q Hoarseness
q Loss of hearing
q Nosebleeds
q Persistent cough
q Photophobia
q Ringing in ears
q Sinus problems
q Eye infections
q Vision—flashes
q Vision—halos
Skin
q Bruise easily
q Eczema
q Hives
q Itching
q Change in moles
q Psoriasis
q Rash
q Scars
q Sore that won’t heal
Men only
q Breast lump
q Erection difficulties
q Lump in testicles
q Penis discharge/sores
q Other
Women only
q Abnormal Pap Smear
q Bleeding between periods
q Breast lump
q Extreme menstrual pain
q Hot flashes
q Nipple discharge
q Painful intercourse
q Vaginal discharge
q Other
Date of last menstrual period?______
Date of last PAP smear?______
Have you had a mammogram?
£ No £ Yes
Are you pregnant? £ No £ Yes
What form of birth control do you use?______
Number of pregnancies? _____
Number of children?______
Washington
Homeopathic
Clinic
Conditions check (P) you have or have had in the past
Washington
Homeopathic
Clinic
q AIDS
q Alcoholism
q Anemia
q Anorexia
q Appendicitis
q Arthritis
q Asthma
q Bleeding disorders
q Breast lump
q Bronchitis
q Bulimia
q Cancer
q Cataracts
q Chemical Dependency
q Chicken Pox
q Colitis
q Diabetes
q Emphysema
q Epilepsy
q Glaucoma
q Goiter
q Gonorrhea
q Gout
q Heart Disease
q Hepatitis
q Hernia
q Herpes
q High Cholesterol
q HIV Positive
q Irritable Bowel Disease
q Kidney Disease
q Liver Disease
q Measles
q Migraine Headaches
q Miscarriage
q Mononucleosis
q Multiple Sclerosis
q Mumps
q Pacemaker
q Pneumonia
q Polio
q Prostate problem
q Psychiatric care
q Rheumatic fever
q Scarlet fever
q Stroke
q Suicide attempt
q Thyroid problems
q Tonsillitis
q Tuberculosis
q Typhoid Fever
q Ulcers
q Vaginal Infections
q Sexually Transmitted Illness
q Whooping cough
Medications and Supplements. List those you are currently taking. / Allergies to medications and substances.Family History
Relation / Age / State
of Health / Age at Death / Cause of Death / Check (P) if your blood relatives had any of the following and describe their relationship to you
Father / £Aneurysms______
£Anxiety______
£Arthritis, gout______
£Asthma______
£Autism______
£Bipolar Disorder______
£Brain Tumors______
£Cancer______
£Cerebral Palsy______
£Chemical Dependency______
£Depression______
£Epilepsy/Seizures______
£Gonorrhea______/ £Headaches/Migraines ______
£Heart Disease______
£High Blood Pressure______
£Kidney Disease______
£Learning Disabilities______
£Mental Retardation______
£Muscular Disease ______
£Obsessive Compulsive DO______
£Schizophrenia______
£Syphilis______
£Tics______
£Tuberculosis______
Mother
Brothers
Sisters
Health Habits check (P) which substances you use and describe how much you use. / Occupational Concerns check (P) if your work expose you to the following:
Caffeine / Stress
Tobacco / Hazardous substances
Alcohol / Heavy lifting
Drugs / Other
Other
Exercise. How often and what kind of exercise do you do?
Serious Illness/Injuries and
Hospitalizations
/ Date / Outcome /Pregnancy History
Year/Date of birth / Complications if any.Preferences, habits, and particulars
Food
/Sleep Habits
Which foods do you crave?
£Sweet £Sour £Salty £Fats £BreadsAppetite? £Good £Fair £Poor
Thirst? £Very thirsty £Medium £Not at all /Bed time? ______
Wake time? ______
Time to fall asleep? ______
Sleep position? ______
/ During sleep do you:£Grind teeth £Snore
£Perspire £Walk
£Talk £Have nightmares?
£Wake at night? Time______
Fears
/Temperature
£Claustrophobia £Dark
£Heights £Flying£Thunder/Lightning £Water
£Animals. Which ones? ______£Other______/ Sense of body temperature? £Chilly £Warm
Hands? £Chilly £Warm
Feet? £Chilly £Warm
Other
/Do you bite your nails? £Yes £No /
Favorite book or movie?
Best time of day? ______Worst time of day? ______ /Do you recall your dreams? £Yes £No