Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1St St. Beaverton, OR 97005

Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556ADULT INTAKEName: ______Date: ______/______/______Address: ______City: ______State: ______Zip Code: ______Phone No. : (______)______E-mail address: ______Date of Birth: ______/______/______Gender: Female: ______Male: ______Education:______Occupation: ______Hours of work per week: ______Employer Name and Address:____________Married Separated Divorced Widowed Single Partnership Live with: Spouse Partner Parents Children Friends Alone How did you hear about our clinic?______Emergency contact: ______Relationship:______Phone: ______Address:______City: ______State: ______Zip Code: ______CONTEXT OF CARE REVIEWSuccessful health care and preventive medicine are only possible when the physician has a complete understanding of the patient physically, mentally, and emotionally. The nature of your response to the following questions will go a long way in assisting my understanding of your truest desires. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to assist your health needs.What expectations do you have from this visit to our clinic1. ______2. ______3. ______Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 1 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556What long term expectations do you have from working with our clinic? ____________What expectations do you have of me personally as your health care provider? ____________What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? Rate from 0 to 10, 10 being 100% committed.0% 0 1 2 3 4 5 6 7 8 9 10 100%What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health?______What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive? ______What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and adhering to the therapeutic protocols which we will be sharing with you? ____________Who do you know that will sincerely and consistently support you with the beneficial lifestyle changes you will be making?______What do you love to do? __________________Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 2 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556Are you currently receiving healthcare? YES NOIf yes, where and from whom? ____________If no, when and where did you last receive medical or health care? ____________What was the reason? ______What are your most important health problems? List as many as you can in order of importance.1) ______2) ______3) ______4) ______5) ______6) ______7) ______Do you have any known contagious diseases at this time? YES NOIf yes, what? ______Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 3 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556FAMILY HISTORYDo you or anyone in your family have a history of any of the following? (please check and say who)Cancer YES NO ______Diabetes YES NO ______Heart Disease YES NO ______High Blood Pressure YES NO ______Kidney disease YES NO ______Epilepsy YES NO ______Arthritis YES NO ______Glaucoma YES NO ______Tuberculosis YES NO ______Stroke YES NO ______Anemia YES NO ______Mental Illness YES NO ______Asthma YES NO ______Hay fever YES NO ______Hives YES NO ______Any other relevant family history?______CHILDHOOD ILLNESSESPlease circle whether you had any of the following as a child:Rheumatic fever Diphtheria Scarlet fever Chicken pox German Measles Measles Mumps Asthma Eczema Any other illnesses ______HOSPITALIZATIONS/SURGERY/IMAGINGWhat hospitalizations, surgeries, x-rays, CAT scans, EEG, EKGs have you had?______year ______year ____________year ______year ____________year ______year ____________year ______year ______ALLERGIESAre you hypersensitive or allergic to:Any drugs? ______Any foods? ______Any environmentals or chemicals? ______Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 4 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556CURRENT MEDICATIONSDo you take or use any of the following (please circle):Laxatives Pain relievers Antacids CortisoneTranquilizers Sleeping Pills Thyroid Medication Birth Control PillsAntibiotics Hormone ReplacementPlease list any prescription medications, over the counter medications, vitamins or other supplements you are taking and their doses1) ______5) ______2) ______6) ______3) ______7) ______4) ______8) ______Past Medications useLaxatives Pain relievers Antacids CortisoneTranquilizers Sleeping Pills Thyroid Medication Birth Control PillsAntibiotics Hormone ReplacementGENERALHeight: ______Weight: ______Weight one year ago: ______Maximum Weight: ______When: ______When during the day is your energy the best? ______Worst:______Main interests and hobbies: ____________Exercise: YES NO If so, what kind and how often: ______Watch TV: YES NO If so, how many hours?______Read: YES NO How many hours?______TYPICAL FOOD INTAKEBreakfast:______Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 5 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556Lunch:______Dinner:______Snacks:______To Drink: ______REVIEW OF SYSTEMSY = Yes P = Problem in the past N = No General NeurologicDo you sleep well? Y N P Seizures? Y N PAverage 6-8 hours? Y N P Muscle weakness? Y N PAwake rested? Y N P Loss of memory? Y N PHave a supportive relationship?Y N P Vertigo or dizziness? Y N PHave a history of abuse? Y N P Paralysis? Y N PExperienced a major trauma?Y N P Numbness or tingling? Y N PUse recreational drugs? Y N P Easily stressed? Y N PTreated for drug dependence?Y N P Loss of balance? Y N PUse alcoholic beverages? Y N P EndocrineUse tobacco? Y N P Hypothyroid? Y N PIf in the past, how many years? ______Hypoglycemia? Y N PHow many packs per day? ______Excessive thirst? Y N PDo you enjoy your work? Y N P Fatigue? Y N PTake vacations? Y N P Heat or cold intolerance? Y N PSpend time outside? Y N P Hyperthyroid? Y N PEat three meals a day? Y N P Diabetes? Y N PDo you go on diets often? Y N P Excessive hunger? Y N PDo you eat out often? Y N P Seasonal depression? Y N PDr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 6 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556Do you drink coffee? Y N P Difficulty exercising? Y N PDrink black/green tea? Y N P ImmuneDrink soda? Y N P Reactions to immunizations?Y N PDo you eat refined sugar? Y N P Chronically swollen glands? Y N PDo you add salt to your food?Y N P Slow wound healing? Y N PDr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 7 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556Immune Continued Hayfever? Y N PChronic fatigue syndrome?Y N P Loss of smell? Y N PChronic infections? Y N P NeckNight sweats? Y N P Lumps in neck? Y N PEars Goiter? Y N PImpaired hearing? Y N P Difficulty swallowing? Y N PRinging in ears? Y N P Pain or stiffness in neck? Y N PDizziness? Y N P Mouth and ThroatEar aches? Y N P Frequent sore throat? Y N PEyes Copious saliva? Y N PImpaired vision? Y N P Sore tongue or lips? Y N PCataracts? Y N P Hoarseness? Y N PGlaucoma? Y N P Jaw clicks? Y N PSpots in vision? Y N P Teeth grinding? Y N PColor blindness? Y N P Gum problems? Y N PTearing or dryness? Y N P Dental cavities? Y N PEye pain or strain? Y N P SkinHead Rashes? Y N PHeadaches? Y N P Acne/boils? Y N PMigraines? Y N P Change in skin color? Y N PHead injury? Y N P Lumps or bumps on skin? Y N PJaw or TMJ problems? Y N P Eczema or hives? Y N PNose and Sinus Itching? Y N PFrequent colds? Y N P Perpetual hair loss? Y N PStuffiness? Y N P RespiratorySinus problems? Y N P Cough? Y N PNose bleeds? Y N P Sputum? Y N PDr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 8 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556Respiratory continued Black stools? Y N PAsthma? Y N P Blood in stools? Y N PWheezing? Y N P Mental/EmotionalBronchitis? Y N P Treated for emotional problem?Y N PCoughing up blood? Y N P Depression? Y N PShortness of breath? Y N P Anxiety or nervousness? Y N PShortness when lying down?Y N P Poor concentration? Y N PPain in breathing? Y N P Do you have mood swings? Y N PEmphysema? Y N P Considered suicide? Y N PTuberculosis? Y N P Attempted suicide? Y N PGastrointestinal Tension? Y N PTrouble swallowing? Y N P Memory problems? Y N PChange in thirst? Y N P UrinaryChange in appetite? Y N P Increased frequency of Y N PNausea/Vomiting? Y N P urination? Y N PUlcer? Y N P Inability to hold urine Y N PJaundice? Y N P Pain in urination? Y N PGall bladder disease? Y N P Frequency at night? Y N PLiver disease? Y N P Frequent UTIs? Y N PHemorrhoids? Y N P Kidney stones? Y N PPancreatitis? Y N P MusculoskeletalHeartburn? Y N P Joint pain or stiffness? Y N PAbdominal pain or cramps?Y N P Arthritis? Y N PBelching or passing gas? Y N P Broken bones? Y N PConstipation? Y N P Weakness? Y N PBowel movements: how often? ______Muscle spasm or cramps? Y N PIs this a change? ______Sciatica? Y N PDr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 9 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556Blood Bleeding between cycles? Y N PAnemia? Y N P Clotting? Y N PEasy bleeding or bruising? Y N P Endometriosis? Y N PCold hands/feet? Y N P Ovarian cysts? Y N PDeep leg pain? Y N P Vaginal odor? Y N PThrombophlebitis? Y N P Vaginal discharge? Y N PVaricose veins? Y N P Date of last pap smear: Y N PCardiovascular Abnormal PAP? Y N PHigh blood pressure? Y N P Cervical dysplasia? Y N PHeart palpitations? Y N P Are you sexually active? Y N PAngina? Y N P Sexual orientation: ______Rheumatic fever? Y N P Birth control? Type: ______Murmurs? Y N P Pain during intercourse? Y N PSwelling in ankles? Y N P Gonorrhea? Y N PHeart disease? Y N P Herpes? Y N PHeart Attack? Y N P Chlamydia? Y N PFemale reproductive Genital warts? Y N PAge of first menses: ______Syphilis? Y N PAge of last menses (if menopausal): ______Difficulty conceiving? Y N PLength of cycle: ______Number of pregnancies: ______Duration of menses: ______Number of live births: ______Are you cycles regular? Y N P Number of miscarriages: ______Painful menses? Y N P Number of abortions: ______Heavy or excessive flow? Y N P Do you do self breast exams?Y N PPMS? Y N P Breast pain/tenderness? Y N PSymptoms: ______Breast lumps? Y N P______Nipple discharge? Y N PDr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 10 Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556Female reproductive continued Genital warts? Y N PMenopausal symptoms? Y N P Herpes? Y N PMale reproductive Syphilis? Y N PAre you sexually active? Y N P Hernias? Y N PSexual orientation: Y N P Testicular masses? Y N PBirth control? Type: Y N P Testicular pain? Y N PDischarge or sores? Y N P Prostate disease? Y N PChlamydia? Y N P Impotence? Y N PGonorrhea? Y N P Premature ejaculation? Y N PIs there any information about your health that you would like to add?______________________________Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1st St. Beaverton, OR 97005 Phone: 971-217-6556 11

Dr. Soniya Gandhi, N.D., B.H.M.S. Ocean Natural Health 12555 SW 1St St. Beaverton, OR 97005

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