HIGH DESERT NATUROPATHIC CARE
Deborah M. Keller, ND, LM, CPM
 2019 Galisteo St., Suite E2, Santa Fe, NM 87505
 Tel: 505/670-9042

CONFIDENTIAL PATIENT INFORMATION (ADULT)
DATE:__________

Patient's Name:______________________________ Age:_____ Sex:_____ Birth date:_____________

Address:_____________________________________ City:________________ State:_____ Zip:_____

Phone (home):_______________ (work):_______________ E-mail:_____________________________

Occupation:_________________________ Employer or School:_______________________________

Marital Status:_______________________ Social Security #:_________________________________

Person to be contacted in case of Emergency:_________________________ Relationship:_________

Address:___________________________________________________________ Phone:____________

Your Primary Care Physician or person you see regularly for health care:_________________________

How did you hear about Dr. Keller?________________________________________________________

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PLEASE LIST THE HEALTH CONCERNS THAT BRING YOU IN TODAY

1.
2.
3.

Are you willing to change your lifestyle habits to improve your health? (circle one) YES NO

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MEDICATIONS

now past frequency
Pain Relievers (List types used) ___ ___ _______
Antibiotics ___ ___ _______
Decongestants ___ ___ _______
Laxatives ___ ___ _______
Thyroid ___ ___ _______
Blood Pressure ___ ___ _______
Antidepressants ___ ___ _______
All Other (please list) ___ ___ _______

Please list all vitamins, herbs, homeopathic, or other supplements that you are taking:_______________
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ALLERGIES (to medications, supplements, foods, or environment)_______________________________
______________________________________________________________________________________

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PAST SURGERIES/HOSPITALIZATIONS
Please list dates and reason for any surgeries or hospitalizations:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

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HEALTH HISTORY

Please put an N if you have the condition now; P for in the past; B for both:

___ Measles ___ Scarlet Fever ___ Angina
___ Mumps ___ Rheumatism ___ Heart Murmur
___ Influenza ___ Bronchitis ___ Fatigue
___ Mononucleosis ___ Herpes (oral) ___ Muscle Weakness
___ Hay Fever ___ Herpes (genital) ___ Diarrhea
___ Headaches ___ Shingles ___ Constipation
___ Dizziness ___ Gonorrhea ___ Cough/Wheezing
___ Hives ___ Insomnia ___ Indigestion/Gas
___ Pneumonia ___ Jaundice ___ Anxiety
___ Colitis ___ Ringing in the Ears ___ Backaches
___ Joint Pain ___ Bladder Infection ___ Strep Throat
___ Frequent Infections ___ Memory Loss ___ Moodiness

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FAMILY HISTORY
Please check Self if you have had any of the following. Also, please identify any family member(s) that have
had any of the following:
Self Family Member(s)
Allergies ___ ____________
Alcoholism ___ ____________
Asthma ___ ____________
Autoimmune Disorder ___ ____________
Bleeding Disorder ___ ____________
Cancer ___ ____________
Diabetes ___ ____________
Epilepsy ___ ____________
Heart Disease ___ ____________

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HEALTH & LIFESTYLE HABITS
Do you use tobacco? ______ If yes, how much per day? ______ For how long? ______
How often do you drink wine? ______ beer? ______ other alcohol? ______
How often do you drink coffee? ______
How often do you drink soda pop? ______
Diet restrictions? ______________________________________________________________
How often do you exercise? __________________ Form(s) of exercise _________________
List any chemicals, fumes, dust, etc. that you are repeatedly exposed to: _______________
____________________________________________________________________________

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