BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY
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1 BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural health care. The ability to draw effective conclusions about your state of health and how to optimize its improvement may be influenced by many factors. The information from this form will assist to provide you with an optimal plan of health care. Date First Name Middle Last Address City State Zip Code Home Phone ( ) - Work ( ) - Cell ( ) - Age Date of Birth / / Gender: o Female o Male Marital Status: o Single o Married o Divorced o Widowed o Long Term Partnership Genetic Background please check appropriate box(es): o Caucasian o Native American o African American o Hispanic o Mediterranean o Asian o Other Occupation Hours per week Nature of Business Emergency Contact: Phone Name, address, & phone number of primary care physician: BACK TO BASICS HEALTH & NUTRITION Page 1
2 SYMPTOMS AND AREAS OF CONCERN Please check all that apply. o Acne o ADD/ADHD o Adrenal Glands o Allergies o Alzheimer s Disease o Anemia o Anger o Anxiety o Appetite o Arteriosclerosis o Arthritis o Asthma o Back Pain o Bad Breath o Bed Wetting o Bell s Palsy o Bites o Bladder o Blood Pressure - High o Blood Pressure - Low o Boils o Bones o Breathing o Bronchitis o Bruises o Burns o Cancer o Candida o Canker Sores o Carpal Tunnel o Cataracts o Chest Congestion o Chest Pain o Cholesterol o Circulation o Cold - Common o Cold - Temperature o Colic o Colon o Constipation o Cough o Cravings o Dandruff o Depression o Diabetes o Diarrhea o Digestion o Dizzy Spells o Ear Infection o Ear Ringing o Edema o Emphysema o Epilepsy o Eyesight o Fatigue o Fever o Flu o Gallstones o Gangrene o Gas o Gout o Gums o Hair Issues o Headache o Heart Issues o Heartburn o Hemorrhoids o Herpes o Hiatal Hernia o Hives o Hormones o Hyperactive o Hypertension o Hyperthyroidism o Hypoglycemia o Impotence o Incontinence o Indigestion o Insomnia o Joint Pain o Kidney Issues o Kidney Stones o Laryngitis o Leprosy o Leukemia o Liver o Lung Issues o Lupus o Lymph Glands o Menopause o Menstrual Cramps o Migraines o Mononucleosis o Mucous o Nails o Nausea o Nervousness o Nose Bleeds o Parasites o Parkinson's Disease o Perspiration o PMS o Pneumonia o Polyps o Pregnancy o Prostate o Psoriasis o Rash o Reproductive o Respiratory o Rheumatism o Ring Worm o Seizures o Shingles o Sinus o Skin Issues o Snoring o Sore Throat o Stomach o Stress o Stroke o Sty o Teething o Tennis Elbow o Tonsillitis o Tumors o Ulcers o Urinary Infections o Varicose Veins o Vertigo o Weight o Yeast Infections Other Symptoms/Concerns BACK TO BASICS HEALTH & NUTRITION Page 2
3 SYMPTOMS AND AREAS OF CONCERN (continued) What medical diagnosis or explanation(s), if any, have been given to you for these symptoms/concerns? What physician or health care providers (alternative practitioners) have you seen for these conditions? MEDICATIONS List all medications include all over the counter non-prescription drugs. Medication Name Date Started Date Stopped Dosage List all vitas, erals, and any nutritional supplements that you are taking now. Type Date Started Date Stopped Dosage Are you allergic to any medication, vita, eral, or other nutritional supplement? o Yes o No If yes, please list: BACK TO BASICS HEALTH & NUTRITION Page 3
4 NUTRITIONAL Do you currently follow a special diet or nutritional program? o Yes o No Are you any of the following: o Paleo o Diabetic o Dairy Restricted o Vegetarian o Vegan o Blood Type Diet o Keto o Other (describe) Is there is anything special about your diet: Do you have symptoms immediately after eating, such as belching, bloating, hives, etc? o Yes o No If yes, are these symptoms with a particular food or supplement? Does skipping meals greatly affect you? o Yes o No Do you have an aversion to certain foods? o Yes o No If yes, what food(s) What foods do you crave? How much of the following do you consume? (1D=once daily, 2W=twice a week, 3M=three times a month) Soda Pop Coffee Smoking Alcoholic Bev Fast Food Milk White Flour Sugar Usage Raw Fruit Meat Raw Veggies Whole Grains LIFESTYLE Do you smoke? o Yes o No If yes, how much? Are you exposed to 2nd hand smoke regularly? o Yes o No If yes, please explain: Average number of hours that you sleep at night? o less than 6 o 6-8 o 8-10 o more than 10 BACK TO BASICS HEALTH & NUTRITION Page 4
5 LIFESTYLE (continued) Do you exercise regularly? o Yes o No If yes, please indicate: Type of exercise Jogging/Walking Times/Week 1x 2x 3x 4x/+ 15 Length of Session >45 Aerobics Strength Training Pilates/Yoga/Tai Chi Sports (tennis, golf, water sports, etc) Other (please list below) If no, please indicate what problems limit your activity (e.g., lack of motivation, fatigue after exercising, etc.) What are your top 3 health concerns? Who referred you for your appointment today? I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is a personal istry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease. Signature Date BACK TO BASICS HEALTH & NUTRITION Page 5
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ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
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NEW PATIENT QUESTIONNAIRE
Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program
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TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip