Natural Health Center, LLC
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- Kerry Stafford
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1 1 Natural Health Center, LLC compassionate care changing lives 3330 EAGLE STREET ANCHORAGE, AK T (907) F (907) Today s Date Patient s Name Age Birth Date & Place Occupation Marital Status: Single Mar. Div. Wid. Sep. Domestic Partner What is your major complaint? Now GENERAL SYMPTOMS Now EYES tired, weak, lack of energy nearsightedness or farsightedness frequent colds or illnesses blurred or failing vision, double vision, spots before eyes worry, anxiety, nervousness, irritability dry, burning or itching eyes headaches eyes water excessively don t sweat enough eyes sensitive to light sweat too much night blindness dizziness, fainting, convulsions tend to be chilly tend to be warm Date of last eye exam: sleep problems: (sleep too much, can not get to sleep, wake during the night, restless) drug allergies (known or suspected) EARS earaches, ear infections list: noises or ringing in ears ear discharges SKIN AND HAIR loss of hearing acne or pimples lots of wax skin rashes, eruptions, boils, eczema hives, itching stretch marks skin ulcers or sores NOSE AND THROAT hay fever, sinusitis, runny nose dryness, roughness, or scaling skin, scalp, knees, feet, dry mouth or nose around nose, ears, etc. nose bleeds hair loss or thinning, change in color cracks in corners of mouth dry, coarse hair or split ends dry or chapped lips bruise easily sore throat throat or tonsillitus nails weak, ridged or split easily canker sores brown spots or bronzing on skin sore, red or cracked tongue moles, warts or skin tags cold sores or herpes sunburn easily inability to smell or taste hands or feet numb or tingling lots of cavities, toothaches athlete s foot bleeding gums, gum infections hoarseness allergies MUSCULO-SKELETAL chronic congestion, post nasal drip Date of last dental exam fractures / frequent dislocations bone pains painful feet, ankles or calves tremors or twitches, cramps loss of strength / muscle wasting Date of last bone density scan (DEXA) Was it: Normal Abnormal
2 Now cough frequently R E SPI R A T OR Y spitting up mucus or blood wheezing shortness of breath on exertion chest pain pneumonia / bronchitis / pleurisy Now C A R DI OV A SC UL A R heart beats fast or irregularly tightness in chest, full heavy feeling in chest discomfort at high altitude dizzy or weak when standing up swollen feet, ankles or legs cold hands or feet hand or feet turn blue at night, triggered by emotion exposure to toxic fumes, dust, chemicals or substances smoker blue fingernails leg pains when walking varicose veins, phlebitis heart murmur Date of last TB exam /_/ high blood pressure Date of last chest x-ray _/_/_ low blood pressure loss of hair on legs GASTROINTESTINAL toe or leg ulcers increased appetite or thirst loss of appetite or thirst heart attack nausea or vomiting URINARY bad breath metallic or bitter taste in mouth can not eat fats or greasy foods jaundice heartburn indigestion or distress use of antacids heaviness after eating gas or belching bloating stomach or abdomen tender or painful symptoms relieved by eating headache, dizziness or irritability if skip meals anorexia difficulty urinating urinate frequently at night bedwetting incomplete urination or dribbling narrowing of stream hard to start stream change in color, odor, frequency of urine incontinence (uncontrolled urination) pain when urinating, burning bladder infections kidney infections, disease kidney stones lower back pain history of IV P (kidney x-rays) bulimia diarrhea or loose stool constipation NEUROLOGICAL/PSYCHOLOGICAL alternating constipation / diarrhea dizziness change in bowel movements fainting, blackouts light colored or greasy stools seizures or convulsions dark stools tingling, numbness blood in stool, mucus in stool problems walking feeling of incomplete evacuation lack of coordination undigested food in stool speech problems foul odor of stool or gas preoccupations hemorrhoids impulsive anal itching, bleeding shy use of laxatives nervous breakdown indecision How often do you have a bowel movement? paranoia thoughts of suicide BLOOD / LYMPH confusion excessive bleeding depression, anxiety, mood swings tendency to anemia irritability, cry easily history of iron supplements history of counseling, psychiatric help blood disorder use of psychoactive medications swollen glands type(s): pain or heat in lymph nodes fears (of what): 2
3 Now F E M A L E irregular menstruation pain prior to or with periods discharge from breasts symptoms occur in monthly pattern diminished or increased sexual desire Now having orgasm inability to conceive miscarriages, abortions or tubal pregnancy vaginal discharges pain, discomfort or itching in genital area hot flashes vaginal infections: yeast, trichomonas Are you a DE S * son? M A L E diminished or increased sexual desire gonorrhea, syphilis, chlamydia erectile dysfunction genital herpes prostate problems pain, lump or mass in testicle discharge from penis sores or rashes in genital area infertility Y es No *m prescribed DE S during pregnancy ( ) ovarian cysts genital herpes gonorrhea, syphilis, chlamydia FEMALE (Cont.) Age periods started _ Age of m s menopause Date of last period /_/ Length of cycle days : Light Moderate Heavy Clotting? Spotting? Type of birth control Have you ever used birth control pills or an IUD? What type and for how long? Number of pregnancies Number of children Do you have your uterus and both your ovaries? Date of last PAP smear / / Was it normal? _ Any history of abnormal PAP smear? If yes, when? Are you a DES* daughter? Yes No *m prescribed DES during pregnancy ( ) Have you had a mammogram? When? 3 ILLNESSES, INJURIES, SURGERIES Have you ever been hospitalized or had a serious illness, accident or injury? Include any surgery you have had. W H E N W H A T W H E R E
4 HABITS: (Check appropriate column below) 4 Never R arely Occasionally Weekly Daily (and amount) e Black Tea Alcohol Tobacco Chew/Smoke Laxatives Aspirin Soft Drinks (pop) Chocolate Other drugs DIET EXERCISE Number of meals a day Do you get regular exercise? Number of snacks a day What type? Number of glasses of water a day How often? Do you eat a special diet? Do you have cravings or strong desires for certain foods? (for what) Do you avoid certain foods? (what and why) Any allergies or adverse reactions to foods: Do you include these in your diet? What portion (at moderate frequency) Fast foods Y N ) Y N Fried foods Y N Natural, whole foods Y N Vitamins (please list below) Include therapeutic intent Over-the-counter medications (please list below) Herbs or food supplements (please list below) Include therapeutic intent Prescription medications (please list below) History of antibiotic use: more than twice a year less than once a year Date of last use: / /
5 Have you or any of your family members had any of the problems in this chart? Please indicate who s had which by checking the appropriate space. 5 Condition Self M Father Brs Sisters Grandparents Children Others Alcoholism Allergies Anemia Anorexia/Bulimia Arthritis Asthma Birth Defects Bleeding Disorder Cancer/Leukemia Depression Diabetes Drug Abuse Emphysema Epilepsy or Seizures Gallbladder Disease Glaucoma/Cataracts Gout Heart Attack Heart Disease-circulatory problems Hepatitis or Liver Disease High Blood Pressure Hypoglycemia Kidney or Bladder Disease Kidney Stones Malaria Mental Illness Migraine Headaches Mononucleosis Multiple Sclerosis Muscular Dystrophy Obesity Osteoporosis Physical Abuse Rheumatic Fever Sexual Abuse Scoliosis (curvature of the spine) Stroke Suicide Thyroid Problems, Goiter Tuberculosis (TB) Ulcers Sexually Transmitted Diseases Other:
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