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1 Health History Name Date Address City State Zip Code Phone Occupation Age Height Sex Number of Children Marital Status: Single Partner Married Separated Divorced Widow(er) Are you recovering from a cold or flu? Are you pregnant? Reason for office visit Date began List current health problems for which you are being treated: What types of therapies have you tried for these problem(s) or to improve your health overall: Diet modification Fasting Vitamins/minerals Herbs Homeopathy Chiropractic Acupuncture Conventional drugs Other Do you experience any of these general symptoms on a regular basis? Debilitating fatigue Shortness of breath Insomnia Constipation Chronic pain/inflammation Depression Panic attacks Nausea Fecal incontinence Bleeding Disinterest in sex Headaches Vomiting Urinary incontinence Discharge Disinterest in eating Dizziness Diarrhea Low grade fever Itching/rash Current medications (prescription or over-the-counter): Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis): Outcome: Major hospitalization, surgeries, injuries. Please list all procedures, complications (if any), and dates: Year Surgery, illness, or injury Outcome Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): Identify the major causes of stress (e.g., changes in job, residence or finances): Do you consider yourself: Underweight Overweight Healthy weight Your weight today: Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months? Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) and/or life threatening activities (e.g., firefighter, police officer, etc.)? What are your current health goals:
2 Health History Medical History Arthritis Allergies/hay fever Asthma Alcoholism Alzheimer s disease Autoimmune disease Blood pressure problems Bronchitis Cancer Chronic fatigue syndrome Carpal tunnel syndrome Cholesterol, elevated Circulatory problems Colitis Dental problems Depression Diabetes Diverticular disease Drug addiction Eating disorder Epilepsy Emphysema Eyes, ears, nose, throat problems Environmental sensitivities Fibromyalgia Food intolerance Gastroesophageal reflux disease Genetic disorder Glaucoma Gout Heart disease Infection, chronic Inflammatory bowel disease Irritable bowel syndrome Kidney or bladder disease Learning disabilities Liver or gallbladder disease (stones) Mental illness Mental retardation Migraine headaches Neurological problems (Parkinson s, paralysis) Sinus problems Stroke Thyroid trouble Obesity Osteoporosis Pneumonia Sexually transmitted disease Seasonal affective disorder Skin problems Tuberculosis Ulcer Urinary tract infection Varicose veins Medical (Men) Benign prostatic hyperplasia Prostate cancer Decreased sex drive Infertility Sexually transmitted disease Medical (Women) Menstrual irregularities Endometriosis Infertility Fibrocystic breasts Fibroids/ovarian cysts Premenstrual syndrome (PMS) Breast cancer Pelvic inflammatory disease Vaginal infections Decreased sex drive Sexually transmitted disease Date of last GYN exam Mammogram + PAP + Form of birth control # of children # of pregnancies C-section Age of first period Date of last menstrual cycle Length of cycle days Interval of time between cycles days Any recent changes in normal menstrual flow (e.g., heavier, large clots, scanty) Surgical menopause Menopause Family Health History (Parents and Siblings) Arthritis Asthma Alcoholism Alzheimer s disease Cancer Depression Diabetes Drug addiction Eating disorder Genetic disorder Glaucoma Heart disease Infertility Learning disabilities Mental illness Mental retardation Migraine headaches Neurological disorders (Parkinson s, paralysis) Obesity Osteoporosis Stroke Suicide Health Habits Tobacco: Cigarettes: # /day Cigars: # /day Alcohol: Wine: # glasses/d or wk Liquor: # ounces/d or wk Beer: # glasses/d or wk Caffeine: Coffee: # 6 oz cups/d Tea: # 6 oz cups/d Soda w/caffeine: # cans/d Other sources Water: # glasses/d Exercise 5-7 days/wk 3-4 days/wk 1-2 days/wkk 45 minutes or more duration per workout minutes duration per workout Less than 30 minutes Walk: #days/wk Run, jog, other aerobic - #days/wk Weight lift: #days/wk Stretch: #days/wk Nutrition & Diet Mixed food diet (animal and vegetable sources) Vegetarian Vegan Salt restriction Fat restriction Starch/carbohydrate restriction The Zone Diet Total calorie restriction Specific food restrictions: dairy wheat eggs soy corn all gluten Other Food Frequency Number of servings per day: Fruits (citrus, melons, etc.) Dark green or deep yellow/orange vegetables Grains (unprocessed) Beans, peas, legumes Dairy, eggs Meat, poultry, fish Eating Habits Skip meals (which ones) One meal/day Two meals/day Three meals/day Graze (small frequent meals) Generally eat on the run Eat constantly whether hungry or not Current Supplements Multivitamin/mineral Vitamin C Vitamin E EPA/DHA Evening primrose/gla Calcium, source Magnesium Zinc Minerals (describe) Friendly flora (acidophilus) Digestive enzymes Amino acids CoQ10 Antioxidants (e.g., lutein, resveratrol) Herbs Homeopathy Protein shakes Superfoods (e.g., bee pollen, phytonutrient blends) Liquid meals I Would Like to: Energy, Vitality Feel more vital Have more energy Have more endurance Be less tired after lunch Sleep better Be free of pain Get less colds and flu Get rid of allergies Not be dependent on over-the-counter medications like aspirin, ibuprofen, antihistamines, sleeping aids, etc. Stop using laxatives and stool softeners Improve sex drive Body Composition Lose weight Burn more body fat Be stronger Have better muscle tone Be more flexible Stress: Mental and Emotional Learn how to reduce stress Think more clearly and be more focused Improve memory Be less depressed Be less moody Be less indecisive Feel more motivated Life Enrichment Reduce my risk of degenerative disease Slow down accelerated aging Maintain a healthier life longer Change from a treating-illness orientation to creating a wellness lifestyle FLT Metagenics, Inc. FirstLine Therapy is a registered trademark of Metagenics, Inc. All Rights Reserved.
3 Metabolic Detoxification Questionnaire Part 1: Symptoms Name Date Rate each of the following symptoms based on how you ve been feeling for the: Past 48 hours Past week Past 30 days Point Scale 0 Never or almost never have the symptoms 2 Occasionally have it; effect is severe 1 Occasionally have it; effect is not severe 3 Frequently have it; effect is not severe 4 Frequently have it; effect is severe Head Eyes Ears Nose Mouth/ Throat Skin Heart Lungs Headaches Faintness Dizziness Insomnia Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (does not include near- or farsightedness) Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing loss Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation Chronic coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums, or lips Canker sores Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing Digestive Tract Joints/ Muscles Weight Energy/ Activity Mind Emotions Other Nausea, vomiting Diarrhea Constipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach pain Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness Poor memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression Frequent illness Frequent or urgent urination Genital itch or discharge For Practitioner Use Only: Urinary ph Grand
4 Metabolic Detoxification Questionnaire Part 2: Xenobiotic Tolerability Test (XTT) 1. Are you presently using prescription drugs? If yes, how many are you currently taking? (1 pt. each) 2. Are you presently taking one or more of the following over-the-counter drugs? Cimetidine (2 pts.) Acetaminophen (2 pts.) Estradiol (2 pts.) 3. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them: Experience side effects; drug(s) is (are) efficacious at lowered dose(s) (3 pts.) Experience side effects; drug(s) is (are) efficacious at usual dose(s) (2 pts.) Experience no side effects; drug(s) is (are) usually not efficacious (2 pts.) Experience no side effects; drug(s) is (are) usually efficacious (0 pt.) 4. Do you currently within the last 6 months have you regularly used tobacco products? Yes (2 pts.) No (0 pt.) 5. Do you have strong negative reactions to caffeine or caffeine-containing products? Don t know (0 pt.) 6. Do you commonly experience brain fog, fatigue, or drowsiness? 7. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors? Don t know (0 pt.) 8. Do you feel ill after you consume even small amounts of alcohol? Don t know (0 pt.) 10. Do you have a personal history of: Environmental and/or chemical sensitivities (5 pts.) Chronic fatigue syndrome (5 pts.) Multiple chemical sensitivity (5 pts.) Fibromyalgia (3 pts.) Parkinson s type symptoms (3 pts.) Alcohol or chemical dependence (2 pts.) Asthma (1 pt.) 11. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents? 12. Do you have an adverse or allergic reaction when you consume sulfite-containing foods such as wine, dried fruit, salad bar vegetables, etc.? Don t know (0 pt.) Part 3: Alkalizing Assessment 1. Do you have a history of or currently have kidney dysfunction? 2. Have you ever been diagnosed with hyperkalemia? 3. Are you currently taking diuretics or blood pressure medication? Overall Score Tabulation For Practitioner Use Only: Part 1: Symptoms Grand (High >50; moderate 15-49; low <14) Part 2: XTT (High >10; moderate 5-9; low <4) Part 3: Alkalizing Assessment (High 1) Urinary ph Notes: Patients with high Symptoms but low XTT may be exhibiting pathology that is not related to toxic load. Other mechanisms should be considered, such as inflammation/ immune/allergic gastrointestinal dysfuntion, oxidative stress, hormonal/neurotransmitter dysfunction, nutritional depletion, and/or mind body. Individualize support with specific medical foods, diet, and/or nutraceuticals. Recommend non-alkalizing nutrients if patient answers yes to any questions in the Alkalizing Assessment. FLT Metagenics, Inc. FirstLine Therapy is a registered trademark of Metagenics, Inc. All Rights Reserved.
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6 Food & Lifestyle Journal - Days 2 & 3 Name Date Day 2 Day 3
7 Food & Lifestyle Journal - Days 4 & 5 Name Date Day 4 Day 5
8 Food & Lifestyle Journal - Days 6 & 7 Name Date Day 6 Day 7
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LONGEVITY WELLNESS CENTER 9426 Battle Street, Ste. 201 Manassas, VA 20110 PHONE: 703-272-8501 FAX: 703-272-8502 WEBSITE: www.longevitywellness.net PERSONAL HEALTH HISTORY FORM DEMOGRAPHIC INFORMATION Name
Wynne Huang, M.D. Family Medicine
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Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
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NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there
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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Natural Medicine Center 449 Bay Area Blvd., Houston, TX Phone: Fax: Dr. Robert Rakowski, DC, CCN, DACBN, DIBAK
Natural Medicine Center 449 Bay Area Blvd., Houston, TX 77058 Phone: 281-286-6040 Fax: 281-286-4120 Dr. Robert Rakowski, DC, CCN, DACBN, DIBAK Patient Information Patients Name Date of Birth / / E-Mail
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
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4465 N. oakland ave. Suite 200-S, Shorewood, Wi 53211 Patient Information Name ( ) ( ) ( ) Home PHoNe Work PHoNe Cell Street City State ZiP PlaCe of BirtH maritial StatuS ( ) SiNgle married other in CaSe
Surgical History Please list all operations and dates:
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PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
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Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
Natural Medicine Center 449 Bay Area Blvd., Houston, TX Phone: Fax: Dr. Robert Rakowski, DC, CCN, DACBN, DIBAK
Natural Medicine Center 449 Bay Area Blvd., Houston, TX 77058 Phone: 281-286-6040 Fax: 281-286-4120 Dr. Robert Rakowski, DC, CCN, DACBN, DIBAK Patient Information Patients Name Date of Birth / / E-Mail
I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION
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501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
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Lucas D. Brown, L.Ac. (312)
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
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Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City: