New Patient

Welcome! We look forward to working with you.

Please complete the New Patient Form on this page and Dr. Sadie will get in touch with you as soon as possible.

innerhealthinc@gmail.com

ph: 541-414-5624
fx: 541-550-3890

New Patient Form

Name
First Last
Email
Date
MM slash DD slash YYYY
Phone
Mobile
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referred By
Occupation
Employer
Date of birth
MM slash DD slash YYYY
Age
Sex
- Male
- Female
Height
Weight
Overall Health
- Excellent
- Good
- Fair
- Poor
- Other
Main Complaint (reason for treatment)
Previous treatments for this complaint
Other complaints or problems
Nutritional Supplements being taken
Current Medications/Drugs being taken
Are you currently under the care of a physician or other health care professionals?
If yes, please give name, practice, and date of last visit. Please also include any test results you have access to.
Do you smoke, drink coffee or alcohol? (if yes indicate how much in next question)
- Cigarettes
- Coffee
- Alcohol
How much smoking/coffee/alcohol?
History
List Any Major Illnesses with Approximate Dates
List Any Surgery or Operations with Approximate Dates
Past Accidents or Injuries
Marital Status
- Single
- Married
- Divorced
- Widowed
Name of Spouse
Describe Health of Spouse
Number of Children (if any)
Name of Children
Please also include Age, Sex, and List any physical conditions or concerns.
Any family history (your side only) of serious illnesses
e.g. Cancer, Diabetes, Heart, Other
Any household pets or other animals you or family members are in close contact with
What are your health goals? What are your goals for this appointment?
Primary Concern
Consistency
Diagnosis/Diagnoses
Headaches
- Basal
- Temples
- Cluster
- Crown
- TMJ
- Frontal
Migraine
- prodromal-halluc
- photophobia
- olfaction
- nausea
Ears
- Noise
- Ring
- Hiss
- Pound
- Plug
- Pop
- Ache
- Drain
- Itch
- Loss
- Dizzy
- Wax
Tongue
- Thick
- Coated
- pH
Eyes
- Burn
- Tear
- Ache
- Red
- Dry
- Film
- Itch
- Blur
- Floaters
- Spots
- Tired
- Puffy
- Stye
- Twitch
- Circles
Sinus
- Dry
- Drain
- Plug
- Post
- Sneezing
- Smell
- Loss
- Taste
- Loss
- Thirst
Post:
- white
- yellow
- green
- gray
- brown
- bloody
- clear
- Sore Throat
- Hoarseness
- Cough
- Allergies
- URI
- Fever
- Chills
- Halitosis
- Cankers
- Blisters
- Flu
Cough:
- dry
- productive
- Neck Stiffness
- Shoulder Tension
- Chielosi
- Dry Mouth
- Cold, Sweaty Hands & Feet
- Gums
- Teeth
- Glands
- Dysphagia
Chest
- Tension
- Tightness
- Pressure
- Heavy
- Anxiety
- Congestion
- Pain
- Sternal
- Sharp Heart Pain
- Palpitations
- MVP
- Tachy
- Brady
- Murmur
- Arm Pain
Shortness of Breath
- Constant Exertion
- Asthma
- Wheeze
- Air
- Hunger
- Yawning
- Heartburn
- Indigestion
- aches
- cramps
- nausea
- queasy
- Bloat
- Gas
- Belch
- Ulcer
- HH
Bowels
- Regular
- Incomplete
- Suggish
- Cramps
- Laxative
- Suppositories
- Enemas
- Colonics
- Bulk
Fecal Consistency
- Soft
- Ribbons
- Mucous
- Normal
- Hard
- Pebbles
- Dry
- Pain
- Diarrhea
- Constipation
Hemorrhoids
- History
- Current
- Swollen
- Burn
- Blood
- Distend
- Itch
- Sting
- Ache
- Cramp
Prostate
- burn
- ache
- pain
- restrict
- dribble
- emission
- swell
Vagina
- Burn
- Itch
- Dry
- Pain
- Blood
Discharge
- Clear
- White
- Yellow
- Green
- Brown
- Odor
Menses:
- Regular
- Irregular: early
- Irregular: late
- Skip
- BC
- Pill
- LMP
- Low Abdominal Puffiness
- Breast Tenderness
- Spotting
- Clots
- Breast
- Fluid
- Tired
Flow:
- heavy
- moderate
- light
- long
- brief
Cramps
- mild
- med
- severe
- back
Fluid
- face
- hands
- feet
- body
Acne:
- pre
- mid
- post
PMS
- mood
- swing
- irritable
- depression
Ovulation
- Pains
- Cysts
- Discharge
- Regular
- Irregular
- Fibroids
Breast
- Feeding
- Fibrosis
- Lump
- Discharge
- Prosthesis
- Reduction
- Tenderness
Menopause:
- Natural
- Surgical:
- Partial
- Complete
- Hormones
- Patch
- Flashes
- Formication
- Cramps
- Anxiety
- Acne
- Dry
- Itch
- Fluid
- Cellulite
- Nails
- Spots
- Hair
Urination:
- Nocturnal
- Frequency
- Urgent
- Burn
- Pain
- Odor
- Spasm
- Leak
- UTI
Sleep:
- Difficulty Falling Asleep
- Insomnia
- Interrupted
- Sleep
- Craving
- Jolts
- Dreams
- Nightmares
- Night Sweats
- Restlessness
Sleep hours per night
- Sad
- Grief
- Depression
- Moodiness
- Irritable
- Worrisome
- Angry
- Nervous
- Frustrated
- Anxiety
- Panic
- Cry
- Fear
- Shame
Appetite:
- Low
- High
- Sweet
- Coffee
- Tea
- Chocolate
- Beer
- Wine
- Carbohydrates
- Spices
- Ice Cream
- Soda
- Stress
Energy:
- Low
- Variable
- Up
- Slow to Start
- Improving
- Worse
- AM
- PM
- Meals
- Low
- Exercise
Memory
- Name
- Number
- Word
- Coordination
- Concentration
Sexuality
- Flat
- Low
- Normal
- Impotent
- Slow Healing
- Bruising
- Arthralgia
Body Fat{51707c5075f46ce048a1b3f58bce0584ccf402cfe32f043cb014df7ee9c8caab}
Pulse BP
Cholestrol - HDL and Tri