Integrative Consult Patient Background Form

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1 Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a quiet spot and answer these questions before your appointment. You may, of course, skip any question you don't feel comfortable answering. We look forward to meeting with you! Please feel free to use the additional notes section at the end of this form if you need more room for any of your answers. Today s Date: Date of Birth: Last Name: Middle Initial: First Name: Best way to reach you: Address: Home Phone Number: Cell: Work: Address: City: State: Zip: Primary Care Physician s Name: Phone: Address: City: State: Zip: Other health care providers whom you regularly see (please list): What is the main reason you chose to make this appointment? What would you like to achieve as a result of this visit? Page 01 of 07

2 Please state any specific complaint or symptom you want to make sure we discuss. Please list any medical conditions (past and present). Please list any surgical procedures that you have had, and approx year. Have you ever spent a night in a hospital? Please list the reason and date. What labs, X-rays and other studies have you had? Please bring copies of pertinent results so I can review. Please list any prescription medications that you are currently taking. Please list any over-the-counter medications that you take (including herbals, vitamins, other supplements, and - as needed medications). Please list any allergies or allergic reactions that you have had to food, environmental allergens, or medications -and what was the reaction? Page 02 of 07

3 Year of last tetanus booster: Year of last cholesterol test: If you are over 50, year of last colonoscopy: Women - Please list the following - Last menstrual period or age at menopause: Number of Pregnancies: Number of Births: Approximate date of last Pap Smear: Family Health History - Please indicate any health problems with your Mother: Sister(s): Grandparents: Father: Brother(s): Other: Have any of your relatives had the following illnesses, and if so, who (relationship to you)? Breast Cancer: Y N Colon Cancer Or Polyps: Y N Diabetes: Y N Osteoporosis: Y N Hypertension: Y N Heart Attack: Y N Review of Systems - Please place a check in front of any problems you are currently having or wish to discuss. Fever, Chills Night Sweats Hair Loss Unintended Weight Loss Loss Of Appetite Unusual Headaches Fainting Or Blackouts Numbness Or Tingling Loss Of Memory Chronic Fatigue Or Weakness Trouble Sleeping Wide Mood Swings Crying Or Depression Anxiety Or Nervousness Ringing Ears Dizzy Spells Hearing Loss Visual Change Eyes Itching Or Draining Persistent Nasal Congestion/ drip Excessive Sneezing Excessive Snoring Chest Pains With Exercise Other Chest Pain Or Tightness Palpitations Or Irregular Heart Cough Wheezing Shortness Of Breath Coughing Up Blood Frequent Heartburn Trouble Swallowing Abdominal Pain Persistent Nausea Or Vomiting Frequent Diarrhea Frequent Constipation Blood In Stools Frequent Urination Slow Urinary Stream Painful Urination Nighttime Urination Urinary Leakage Blood In Urine Neck Or Back Pain Joint Pain Leg Pain When Walking Leg Or Ankle Swelling Rash Non-healing Sore Changing Or Bleeding Mole Unexpected Lump Women Spotting/irregular Menses Heavy Menses Unusual Vaginal Discharge Brest Pain Or Lump Abnormal Pap Smear Men Difficulty With Erection Discharge Form Penis Pain Or Lump In Testicle Have You Ever Had Cancer Kidney Stones Positive Tuberculin Test Clots In Legs Or Lungs Depression Positive HIV Test Hepatitis Blood Transfusion Seizure Ulcer Or Stomach Bleeding Asthma Exposure To Radiation Needle Drug Use Sexual Transmitted Disease Page 03 of 07

4 The following section of questions relates to Habits. Please try to be as truthful as possible and indicate if there are ones you are more apt to work on changing. Do you smoke cigarettes or cigars currently? Y N In the past? Y N Do you chew tobacco currently? Y N In the past? Y N Do you drink alcohol? Y N In the past? Y N If yes, how many drinks in a day or in a week? Do you use recreational drugs currently? Y N In the past? Y N If yes, which ones and how were they used? Do you use prescription pain medications or anxiety medications more than how they were prescribed? Y N In the past? Y N If yes, which ones and how were they used? Do you drink caffeinated drinks? Y N In the past? Y N If yes, how much and what type of drinks? There is an important connection between our mind and our body. I would like to explore this with you by addressing several areas in you life. Sleep - Overall, how would you say that you sleep at night? School - Are you currently a student? Y N How many years of education have you completed? Do you have any difficulties with learning? Y N Work - What type of work do you do? Do you enjoy your work? Y N Why or why not? Is there anything about your work that negatively affects your mental or physical health? Y N If yes, what? Family - How would you describe your relationship with your family? Social Network - What relationships (other than family) are important to you in your life right now or in the past? Page 04 of 07

5 What do you do for fun? How do you deal with stress? What are you grateful for in your life? Sexual - Have you, or a close family member, ever experienced sexual abuse or assault? Y N Are you satisfied with your sexual relationships? Y N Home - With whom do you currently live? Do you feel safe in all of your current relationships? Y N Spiritual - Are you part of a religious or spiritual community? Y N How big of a role does it play in your life? Nourishment - Tell me about what you eat. Please list all foods and drinks you have consumed in the previous - 24 hours. Include meals, snacks, beverages and condiments. Is this a typical day? Y N If not, why not? Please describe. How many servings of fruit do you eat/drink each day? Note: (Serving = 1 small piece of fruit, ½ cup juice, ½ cup canned or chopped fruit, ¼ cup dried fruit) How many servings of vegetables do you consume each day? Note: (Serving = ½ cup raw or cooked vegetables, 1 cup fresh, green leafy vegetables, ¼ cup dried vegetables, or 1 small piece) Are you currently on a special diet? Y N If so, please describe. What type of oils or spreads do you add to your food? Page 05 of 07

6 What beverages do you drink on a typical day? What is the main factor driving your food choices? Do you feel a direct connection between what you eat and your health? Y N Tell me about any physical activity you do regularly? Do you enjoy being physically active? Y N Why or why not? Do you feel a direct connection between exercising or lack of exercising and your health? Y N Control - How much control do you feel like you have in your life right now? Tell me about a time in your life when you felt most aspects of your life were in balance. Finally, please describe any experience you have had with alternative, complementary, or integrative medicine. Page 06 of 07

7 Additional Notes - Page 07 of 07

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