NEW PATIENT REGISTRATION
Dr. Juniper Martin
11825 SW Greenburg Road
Suite A2
Tigard, OR 97223

Name______________________________________________  Age ________
Birthdate ___/___/______ Sex__________

Address ______________________________________________
City _____________  State _______ Zip  __________

Phone (home) ( _______ )__________________  (work) ( ________) _______________
email __________________________

Occupation _________________________________ Full or Part Time ____  Retired _______

Employer (name and address) __________________________________________________________________________

Soc. Sec.# _____________________________

Married __________ Separated _________ Divorced _______ Widowed ________ Single ______ Cohabiting _________

If patient is a child, please indicate the following:

   Mother’s name __________________________________ Age _____ Marital status ______ Child lives with you? ____

   Father’s name ___________________________________ Age _____ Marital status ______ Child lives with you?____

Name and Address of Relative or Friend in case of Emergency:

Name _________________________________________________
Relationship _________________________________

Address ______________________________________________________
Phone _______________________________

How did you hear about this office? _____________________________________________________________________

Name of Family Doctor, if any? ________________________________________________________________________

REASON FOR THIS VISIT ___________________________________________________________________________ ________________________________________________________________________________________________
________________________________________________________________________________________________

FAMILY HISTORY and PERSONAL HEALTH HISTORY

Please use this list to answer the next two questions.

Anemia

Eczema

Epilepsy

Stomach/Duodenal Ulcer

Bleeding easily

Arthritis/Rheumatism

High blood pressure

Tuberculosis

Genetic Disease

Cancer/tumor

Heart disease

Alcoholism/Drug addiction

Allergies/asthma

Diabetes

Stroke

Nervous breakdown

Hay fever

Glaucoma

Thyroid

Suicide

Alzheimer’s Disease

 

Venereal disease

Other

Has any blood relative had any of the above?  If so, please indicated their relationship to you and name the disease on the lines provided below:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 Have YOU had any of the conditions in the above list?
__________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

Have you had a bad reaction to an immunization? __________________________________________________________

Are you allergic to any medicines or other substances?  If so, please indicate: ____________________________________ __________________________________________________________________________________________________

Have you ever had surgery or been hospitalized?  If so, please indicate when and for what reason:  (Do not include normal pregnancies.)________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

What medicines do you presently take, including supplements, herbs, and nonprescription items? _____________________ ______________________________________________________________________________________________________________________________________________________________________________________________________

Are you exposed to (or live near): factory smoke, electrical substation, a high traffic road, etc.? ______________________ ______________________________________________________________________________________________________________________________________________________________________________________________________

INSURANCE INFORMATION:  Most of our patients are not covered through their insurance companies for naturopathic medicine.  We recognize and appreciate this hardship.  For those who do have insurance coverage for naturopathic medicine, please fill out the following. 

Subscriber’s name (person’s name the insurance is under) ___________________________________________________

Subscriber’s address (if different than patient’s) ___________________________________________________________

Subscriber’s Date of birth ______________ Subscriber’s employer ____________________________________________

Name of Insurance Company ________________________________________ID # ______________________________

Group # _______________________________

If someone other than the PATIENT is responsible for payment, complete the following:

Name of responsible party ____________________________________________________________________________

Phone ___________________ Social Security # ____________________ Relationship to patient ___________________

Address (if different from the patient’s) __________________________________________________________________ ___________________________________________________________________Date of birth ____________________

Please sign and return to the receptionist. I acknowledge that I am financially responsible for all charges whether or not they are covered by insurance.

Signature _________________________________________ Date____________________