Adult Health History
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- Christiana Chandler
- 5 years ago
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1 Carriage House Medicine Jennifer C.Reid, N.D SE Division Dr. Bldg C Gresham, OR (503) Adult Health History SUCCESSFUL HEALTH CARE AND PREVENTATIVE MEDICINE ARE ONLY POSSIBLE WHEN THE PHYSICIAN HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON T UNDERSTAND WITH A QUESTION MARK. Name: Birthdate: Are you currently receiving healthcare? Yes No If yes, where and from whom? What is the reason for this visit? What are your most important health problems? List in the order of importance
2 5. 6. Do you have any known contagious diseases at this time? Y N If yes, what? Do you have a religious/spiritual practice and how important is it in your life? FAMILY HISTORY Age (if living) Health FATHER MOTHER BROTHER SISTER SPOUSE CHILD G=good P=poor Age at death (if deceased) Cancer Diabetes Heart disease High blood pressure Stroke Epilepsy Mental illness
3 Asthma/hayfever/hives Anemia Kidney disease Glaucoma Tuberculosis Cause of death Y= condition you have now N=never had P= a condition you have had in the past CHILDHOOD ILLNESSES: (please circle if you had the condition) Scarlet fever Mumps Rheumatic fever German measles Lyme disease Diptheria Measles Whooping Cough Chicken pox HOSPITALIZATIONS: What hospitalizations or surgeries have you had? year: year: year: X-RAYS AND SPECIAL STUDIES Name any x-rays, CAT scans, MRI s or other special studies you have had: Electrocardiogram: Y N Electroencephalogram: Y N IMMUNIZATIONS:
4 List any additional as well MMR DtAP Polio Tetanus booster Hepatitis B HIB Chicken pox Flu shot DAILY HABITS: Drink alcohol Eat sugar Caffeine Smoke: How long? Amount per week: Amount: How many per day? Exercise: Sleep: Chemical exposure: Relaxation: How often? How much? Pesticides Your methods: Solvents What type? Metals Other Do you eat 3 meals a day? DIET: Please describe a typical day including snacks Breakfast:
5 Lunch: Dinner: Drinks: Snacks: Allergies (to drugs, foods, environmentals): CURRENT MEDICATIONS: Laxatives Pain relievers Antacids Cortisone Appetite suppressants Antibiotics Tranquilizers Thyroid medication Sleeping pills Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking? What do you enjoy most in your life? How much change are you willing to make at this time for your health?
6 Minimal Some Complete Is there any additional information about your health you would like to add? REVIEW OF SYSTEMS: Y= a condition you have now N= never had P= a condition you have had before MENTAL/EMOTIONAL Treated for emotional problems Depression Mood swings Anxiety or nervousness Considered/attempted suicide Tension Poor concentration Memory Problems ENDOCRINE Hypothyroid Heat or cold intolerance Hypoglycemia Diabetes Excessive thirst Excessive hunger Fatigue Seasonal depression IMMUNE Vaccinations Reactions to vaccinations Chronic Fatigue Syndrome Chronic infections Chronically swollen glands Slow wound healing NEUROLOGIC Seizures Paralysis Muscle weakness Numbness or tingling Loss of memory Easily stressed Vertigo or dizziness Loss of balance
7 SKIN Rashes Eczema, hives Acne, boils Itching Color change Perpetual hair loss Lumps Night sweats HEAD Headaches Head injury Migraines Jaw/TMJ problems EYES Spots in eyes Cataracts Impaired vision Glasses or contacts Blurriness Eye pain/strain Color blindness Tearing or dryness Double vision Glaucoma EARS Impaired hearing Ringing Earaches Dizziness NOSE & SINUSES Frequent colds Nose bleeds Stuffiness Hay fever Sinus problems Loss of smell MOUTH & THROAT Frequent sore throat Copious saliva Teeth grinding Sore tongue/lips Gum problems Hoarseness Dental cavities Jaw clicks NECK
8 Lumps Swollen glands Goiter Pain or stiffness RESPIRATORY Cough Sputum Spitting up blood Wheezing Asthma Bronchitis Pneumonia Pleurisy Emphysema Difficulty breathing Shortness of breath at night Shortness of breath lying down Tuberculosis CARIOVASCULAR Heart disease Angina High/low blood pressure Murmurs Blood clots Fainting Rheumatic fever Chest pain Swelling in ankles GASTROINTESTINAL Trouble swallowing Heartburn Change in thirst Change in appetite Nausea Vomiting Vomiting blood Bowel movements, how often Blood in stool Is this a change? Pain or cramps Constipation Belching or passing gas Diarrhea
9 Black stools Gall bladder Jaundice (yellow skin) Ulcer Liver disease Hemorrhoids URINARY Pain on urination Increased frequency Frequency at night Inability to hold urine Frequent infections Kidney stones MALE REPRODUCTION Hernias Testicular masses Testicular pain Prostate disease Venereal disease Discharge or sores Are you sexually active Y N Chlamydia Sexual orientation: Gonorrhea Impotence Condyloma Premature ejaculation Herpes Birth control? Type: Y N Syphilis FEMALE REPRODUCTION Age of first menses: Are cycles regular? Y N Age of last menses: Bleeding between cycles Length of cycle: days Pain during intercourse Duration of menses: days Sexual difficulties Painful mensus Sexual orientation: Heavy of excessive flow Clotting
10 PMS? What are the symptoms? Discharge Birth control? Type: Y N Are you sexually active? Y N Endometriosis Number of pregnancies? Ovarian cysts Number of live births: Difficulty conceiving Cervical dysplasia Number of miscarriages: Number of abortions: Abnormal PAP Menopausal syptoms Venereal disease Do you do breast self-exams? Chlamydia Breast pain/tenderness Gonorrhea Breast lumps Condyloma Nipple discharge Herpes Syphilis MUSCULOSKELETAL Joint pain or stiffness Arthritis Broken bones Weakness Muscle spasms or cramps Sciatica BLOOD/PERIPEHERAL VASCULAR Easy bleeding or bruising Anemia Deep leg pain Cold hands/feet Varicose veins Thrombophlebitis
11 Welcome! We are glad to serve you! If you have questions, please call.
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Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
Current History: What health concerns brought you in to the clinic today? (Order by importance)
Adult Intake Form Personal Information Date: Name: Sex: M F Age: Address: Birth Date: City: Province: Telephone (Home): Email: Postal code: (Work): Would you like to receive my newsletter (contains upcoming
PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING. *(Please circle answer where ever there is a multiple question.)
1 Dr. Stephen Maltais ND, Naturopathic Doctor 88 Dover Mills Road, Port Dover, ON. N0A 1N1 Phone: (519) 583-1234 E-mail: docmaltais@kwic.com www.dovernaturoapth.com INTAKE FORM FEMALE (16 years of age
Acupuncture Patient Health History
Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender/Preferred pronoun: Marital status (please circle one): Single Married Domestic Partnership
Patient Health History Form
Thomas S. Burgoon, M.D. West Chester, PA 19382 Patient Health History Form Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient
Chiropractic Patient Admittance Form
Chiropractic Patient Admittance Form PERSONAL INFORMATION Last Name: Given Name: Initial: Address: City/Province: Postal Code: Home Phone: Work Phone: Cell: E-mail Address: Date of Birth (D/MM/YYYY): Male
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
ANDREWS HEALING ARTS CLINIC 20Dunk Rock Road #2, Guilford, CT Patient Intake Form
Patient Intake Form 1 Date: Dr.: Patient Name: List your health concerns in order of importance: 1) 2) 3) 4) 5) Name and telephone number of Primary Care physician: Family History Father Mother Siblings
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,