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Adult Intake Form

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Personal Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Preferred Phone Number

Gender

Male

Female

Age

Please enter a number less than or equal to 99.

Date of Birth

Single or Married?

Single

Married

Would you like to receive notices from our office?

Yes

No

Employer

Occupation

Name of Emergency Contact

Emergency Contact Phone

How did you hear about our office?

Insurance Information

Name of insurance company

Subscriber's name (this could be you or your partner

Subscriber's employer

Subscriber's date of birth

PLEASE LIST THE HEALTH CONCERN/PROBLEM THAT BRINGS YOU IN TODAY:

Health Concern / Problem #1

Describe your concern or problem.

When did this problem initially start to bother you?

How often does it bother you -- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worst/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem you’d like to share?

Add 2nd heath concern?

Yes, add 2nd concern

Health Concern / Problem #2

Describe your concern or problem.

When did this problem initially start to bother you?

How often does it bother you -- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worst/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem you’d like to share?

Add 3rd health concern?

Yes, add 3nd concern

Health Concern / Problem #3

Describe your concern or problem.

When did this problem initially start to bother you?

How often does it bother you -- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worst/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem you’d like to share?

Current Medications

Please list any prescription or over the counter medications that you are currently taking.

Name of Drug

Dose

Reason for Taking

For how long

Who prescribed

Allergic to any drugs or substances? What?

Please list any vitamins, minerals, herbs or homeopathic remedies that you are presently taking

Please list your current health care providers.

Name

Type

For what reason

Phone (if available)

Hospitalizations, Serious Illnesses and Injuries

Please list reason and dates, excluding non-surgical childbirth

Event

Reason

Date

Date of last full physical exam

Exam Date

Results (normal or other)

Date of last blood work

Blood work date

Results (normal or other)

(Females) Are you pregnant, or is there any chance that you are pregnant?

Yes

No

Do you have any surgical implants? If so, what type and where in your body?

Have you seen a naturopath before?

Yes

If so, how many other naturopaths have you seen?

How long have you been interested in natural medicine?

Lifestyle Habits

Tobacco Usage

Frequency (none, daily, weekly, monthly)

Amount

Do you any history of smoking? If so, how many years? What years?

Coffee

Frequency (none, daily, weekly, monthly)

Amount

Black Tea

Frequency (none, daily, weekly, monthly)

Amount

Soft drinks

Frequency (none, daily, weekly, monthly)

Amount

Alcohol

Frequency (none, daily, weekly, monthly)

Amount

History of significant alcohol consumption or alcoholism?

Please also provide how long and how much.

Recreational drugs

Frequency (none, daily, weekly, monthly)

Amount

History of significant recreational drug use?

Exercise

Frequency (none, daily, weekly, monthly)

Amount

Are you currently sexually active?

-How would you rate your libido (sex drive) on a scale of zero to 10?

Diet

Please describe your typical diet (breakfast, lunch, and dinner), including any guidelines or restrictions that you follow:

Breakfast

Lunch

Dinner

(Optional) Please describe briefly your religious and/or spiritual background/beliefs:

History of Covid and Covid vaccine

Do you recall when you might have contracted Covid? Approximate date(s) would be fine

Have you received any Covid vaccines? If so, which one(s) and the date(s). Ideally list the exact date(s), but approximate date(s) will be fine too.

Patient Profile - Review of Systems (Please answer carefully)

“Y” means you have the condition now. “P” means that you had the condition in the past, but not any more. If you have never had a condition, leave it blank.

General

Height

Weight

Weight changes

Now

Past

Never

Night Sweats

Now

Past

Never

Fatigue

Now

Past

Never

Fever

Now

Past

Never

Mental / Emotional

Depression

Now

Past

Never

Mood Swings

Now

Past

Never

Anxiety or nervousness

Now

Past

Never

Tension

Now

Past

Never

Suicide thoughts

Now

Past

Never

Suicide attempts

Now

Past

Never

Skin

Acne

Now

Past

Never

Eczema

Now

Past

Never

Hives

Now

Past

Never

Rashes

Now

Past

Never

Infection

Now

Past

Never

Growths (such as warts)

Now

Past

Never

Changes in hair/nails

Now

Past

Never

Transdermal skin patches?

Endocrine

Ever had any thyroid problem

Now

Past

Never

Heat or cold intolerance

Now

Past

Never

Hypoglycemia

Now

Past

Never

Excessive thirst

Now

Past

Never

Excessive hunger

Now

Past

Never

Easy weight gain

Now

Past

Never

Head

Headache

Now

Past

Never

Head Injury(such as warts)

Now

Past

Never

Circulation

Deep leg pain

Now

Past

Never

Cold hands / feet

Now

Past

Never

Varicose veins

Now

Past

Never

Eyes

Dryness

Now

Past

Never

Glasses or contacts

Now

Past

Never

Eye pain

Now

Past

Never

Tearing

Now

Past

Never

Double Vision

Now

Past

Never

Blood

Anemia

Now

Past

Never

Easy bleeding or bruising

Now

Past

Never

Ears

Impaired hearing

Now

Past

Never

Ringing (tinnitus)

Now

Past

Never

Ear ache/itch

Now

Past

Never

Dizziness

Now

Past

Never

Heart

Heart disease

Now

Past

Never

High blood pressure

Now

Past

Never

Rheumatic fever

Now

Past

Never

Chest pain

Now

Past

Never

Swelling in ankles

Now

Past

Never

Palpitations, fluttering

Now

Past

Never

Nose & Sinuses

Frequent colds

Now

Past

Never

Nose bleeds

Now

Past

Never

Stuffiness

Now

Past

Never

Sinus problems

Now

Past

Never

Post nasal drip

Now

Past

Never

Respiratory

Cough

Now

Past

Never

Spitting up blood

Now

Past

Never

Wheezing

Now

Past

Never

Difficulty breathing

Now

Past

Never

Shortness of breath

Now

Past

Never

Positive TB test ever?

Now

Past

Never

Mouth & Throat

Frequent sore throat

Now

Past

Never

Sore tongue

Now

Past

Never

Sores in mouth /on lips

Now

Past

Never

Gum problems

Now

Past

Never

Hoarseness

Now

Past

Never

Dental Problems

Now

Past

Never

Fake teeth? How many?

How many amalgam (mercury) fillings?

Dental implants?

If yes, what type?

Dental bridges or partial bridges?

If so, are they metallic?

Any metal of any kind in your mouth?

Digestion

Trouble swallowing

Now

Past

Never

Heartburn

Now

Past

Never

Take heartburn or acid reflux medicines?

Bloating after eating

Now

Past

Never

Change in appetite

Now

Past

Never

Change in thirst

Now

Past

Never

Loose stools

Now

Past

Never

Blood in stools

Now

Past

Never

Belching or gas

Now

Past

Never

Liver/gall bladder disease

Now

Past

Never

Hemorrhoids

Now

Past

Never

Nausea

Now

Past

Never

Vomiting

Now

Past

Never

Bowels move

daily

more

less

Use laxatives? What kind?

Eat plenty of fiber?

Urinary

Pain on urination

Now

Past

Never

Increased frequency

Now

Past

Never

Frequency at night

Now

Past

Never

Inability to hold urine

Now

Past

Never

Bladder infections

Now

Past

Never

Swellings anywhere in body

Now

Past

Never

Female

Age menses began

No. of days menstrual flow

Length of complete cycle

Are cycles regular

Now

Past

Never

Bleeding between periods

Now

Past

Never

Excessive flow

Now

Past

Never

Cramps

Now

Past

Never

PMS

Now

Past

Never

Abnormal vaginal discharge

Now

Past

Never

DATE of LAST PAP Smear

Results were: normal abnormal don't know EVER had an abnormal PAP?

Now

Past

Never

Date of last mammogram?

Ever used birth control pills?

Now

Past

Never

Ever used an IUD?

Now

Past

Never

If so, how long?

No. of pregnancies

No. of live births

No. of miscarriages

No. of abortions

Menopausal symptoms

Now

Past

Never

Still have your own uterus? Yes or No?

Yes

No

Still have your own ovaries? Yes or No?

Yes

No

Musculoskeletal

Joint pain or stiffness

Now

Past

Never

Broken bones

Now

Past

Never

Muscle spasms or cramps

Now

Past

Never

Weakness

Now

Past

Never

Date of last DEXA scan?

Breasts

Do you self exam regularly

Now

Past

Never

Lumps

Now

Past

Never

Pain or tenderness

Now

Past

Never

Nipple Discharge

Now

Past

Never

Neurologic

Fainting

Now

Past

Never

Seizures

Now

Past

Never

Paralysis

Now

Past

Never

Muscle weakness

Now

Past

Never

Numbness or tingling

Now

Past

Never

Loss of memory

Now

Past

Never

Neck

Swollen glands

Now

Past

Never

Pain or stiffness

Now

Past

Never

Male

Hernias

Now

Past

Never

Testicular masses

Now

Past

Never

Testicular pain

Now

Past

Never

Discharge or sores

Now

Past

Never

Venereal disease

Now

Past

Never

Difficulty stopping or starting urination

Now

Past

Never

Prostate problems

Now

Past

Never

Date of last prostate exam

Family History

If you have any significant family medical history, please list them here. Examples: Cancer, heart disease, high blood pressure, diabetes, mental illness, stroke, alcoholism, etc. Please specify if the condition is on your mother's side versus father's side.

Family Medical History Details

Problem List

Please list ANY or ALL medical conditions you have EVER been diagnosed with, starting from birth on?

Personal Medical Conditions

IMPORTANT:

Please prepare a half-page to one-page summary outlining what you would like to discuss with Dr. Sharif during your visit. A brief history of your condition(s)—such as when symptoms began, how they have progressed, and any treatments you’ve tried—would be especially helpful.

Dr. Sharif is a licensed naturopathic physician and classical homeopath with more than 20 years of experience helping patients treat skin conditions naturally.

Contact Dr. Sharif

1629 Queen Anne Ave N, Ste 104

Seattle, WA 98109

Phone: 425-608-9998

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