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 (CHILD)
DATE:__________

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

Name of Parent or Guardian:_____________________________________________________________

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

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

Social Security #:_________________________________

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

Address:___________________________________________________________ Phone:____________

Patient's Primary Care Physician/Pediatrician:______________________________________________

How did you hear about Dr. Keller?________________________________________________________

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PLEASE LIST THE HEALTH CONCERNS THAT BRING YOU IN TODAY

1.
2.
3.

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MEDICATIONS

now past frequency
Pain Relievers (List types used) ___ ___ _______
Antibiotics ___ ___ _______
Decongestants ___ ___ _______
All Other (please list) ___ ___ _______

Please list all vitamins, herbs, homeopathic, or other supplements that the patient is taking:__________
______________________________________________________________________________________
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 ___ Shortness of Breath
___ Mumps ___ Frequent Runny Nose ___ Heart Murmur
___ Influenza ___ Bronchitis ___ Fatigue
___ Mononucleosis ___ Recurring Ear Infections ___ Muscle Weakness
___ Hay Fever ___ Oral Lesions ___ Diarrhea
___ Headaches ___ Shingles ___ Constipation
___ Dizziness ___ Memory Loss ___ Cough/Wheezing
___ Hives/Rashes ___ Insomnia ___ Indigestion/Gas
___ Pneumonia ___ Jaundice ___ Anxiety
___ Colitis ___ Ringing in the Ears ___ Backaches
___ Joint Pain ___ Bladder Infection ___ Strep Throat
___ Frequent Infections ___ Bed Wetting ___ Behavioral Disorder

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FAMILY HISTORY
Please check Self if your child has 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
Is your child exposed to cigarette smoke? __________________________
How often does the patient:
drink soda pop? ______
have caffeine? (i.e. chocolate) ______
drink water? ______
Diet restrictions? ______________________________________________________________
List any chemicals, fumes, dust, etc. that your child is repeatedly exposed to: ____________
____________________________________________________________________________

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