ADULT HEALTH HISTORY FORM. Patient Name: Address: City, State, Zipcode: Telephone (home):

Transcription

1 ADULT HEALTH HISTORY FORM Patient Name: Date: DOB: / / Age: Address: City, State, Zipcode: Telephone (home): Status: Married Separated Divorced Widowed Single Partnership Work Address: Job Status: Full-time Part-time Retired Student Other: Occupation: Hours/week: Employer: Emergency Contact: Relationship to Patient: Emergency Contact Phone: Emergency Contact Address: Natural Integrative Healthcare Patricia L. Diefenbach, ND, MS, CNC, CNS Naturopathic Physician Diefenbach.ND@gmail.com Phone: (703)

2 CONTEXT OF CARE REVIEW Successful health care and preventive medicine are only possible when the provider has a complete understanding of the physical, mental and emotional aspects. The nature of your responses to the following questions will greatly assist my understanding of your innermost goals. Your time, thoughtfulness and honesty in completing this overview will greatly aid me with your health needs. What do you know about a naturopathic approach? What three expectations do you have from this visit? What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Please check your selection below) (0 = not committed and 10 = completely committed) What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? (Please list) What behaviors or lifestyle habits do you currently engage in regularly that you believe are selfdestructive lifestyle habits? (Please list) Page 2 of 13

3 What potential obstacles do you foresee in addressing the lifestyle factors, which are undermining your health and in adhering to the therapeutic protocols, which we will be sharing with you? Who do you know, who will sincerely support you consistently with the beneficial lifestyle changes you will be making? WHEEL OF BALANCE Wellness is a balance of many factors. Using the circle, shade your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, shade the entire pie shape for career. Do the same for each area, starting from the center point radiating outwards. (Print and shade using a pen/pencil or fill in the section below with your numerical responses) Physical Environment Career Family & Friends Money Personal Growth Health Fun & Recreation Significant Other/Romance Physical Environment Career Money Health Significant Other/Romance Fun & Recreation Personal Growth Family & Friends Page 3 of 13

4 Are you currently receiving health care? Yes If yes, where and from whom? No If no, when and where did you last receive medical or health care and what was the reason? What are your most important health problems? List as many as you can in order of importance: Do you have any, known contagious diseases at this time? Yes No (If yes, please list below) CHILDHOOD ILLNESSES Scarlet Fever Y N Mumps Y N Diphtheria Y N Measles Y N Rheumatic fever Y N German Measles Y N HOSPITALIZATIONS AND SURGERY What hospitalizations or surgeries have you had? Page 4 of 13

5 X-RAYS AND SPECIAL STUDIES X-rays, CAT scans, or other studies you have had: Has your ever had an electrocardiogram? Yes No IMMUNIZATIONS (Please indicate any adverse reactions) Pertussis Polio Measles/Mumps/Rubella Tetanus shot Diptheria Chickenpox Hepatitis Other: ALLERGIES Are you hypersensitive or allergic to any drugs? Yes No (If yes, please list below) Are you hypersensitive or allergic to any foods? Yes No (If yes, please list below) Are you hypersensitive or allergic to any environmental or chemical sensitivities? Yes No (If yes, please list below) CURRENT MEDICATIONS Do you take or use? Laxatives Y N Pain relievers Y N Cortisone Y N Appetite suppressants Y N Tranquilizers Y N Thyroid medications Y N Antacids Y N Antibiotics Y N Sleeping Pills Y N Page 5 of 13

6 Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking GENERAL Height: Weight: lbs. Weight 1 year ago: lbs. Maximum Weight: When: At what part of the day is your energy level the best? At what part of the day is your energy level the worst? TYPICAL FOOD INTAKE Breakfast Lunch Dinner Snacks Beverages Page 6 of 13

7 FAMILY HISTORY Do you have a family history of any of the following? (Please select and indicate relation) Cancer Anemia High blood pressure Diabetes Mental Illness Tuberculosis Epilepsy Heart disease Hayfever Arthritis Glaucoma Kidney disease Hives Asthma Stroke What is your heritage? African Asian Celtic Nordic Other: Any other relevant family history? Page 7 of 13

8 HABITS What are your main interests and hobbies? Do you exercise? Yes No (If yes, please list what kind below) CONDITIONS (Please make your selection from the following) Average 6-8 hrs. sleep Enjoy your work Awaken rested Take vacations Have a supportive relationship Watch television Hours: Have a history of abuse Read Hours: Any major traumas Use recreation drugs Been treated for drug dependence Treated for alcoholism Use alcoholic beverages Do you use tobacco Smoked previously? How many years? Do you eat 3 meals a day? Do you go on diets often? Do you eat out often? Do you drink coffee? Drink black/green tea? Drink cola/soda? Do you eat refined salt? Do you add salt? How many packs per day? Do you have a religious or spiritual practice? Page 8 of 13

9 REVIEW OF SYSTEMS Mental/Emotional Treated for emotional problems Depression Mood Swings Considered/Attempted suicide Poor concentration Anxiety or nervousness Tension Memory Problems Immune Reactions to immunizations Reactions to vaccinations Chronic Fatigue Syndrome Chronically swollen glands Chronic/Recurring infections Slow wound healing Endocrine Hypothyroid Heat or cold intolerance Hypoglycemia Excessive thirst Fatigue Numbness or tingling Easily stressed Loss of balance Neurologic Seizures Paralysis Muscle weakness Loss of memory Vertigo or dizziness Numbness or tingling Easily stressed Loss of balance Skin Rashes Eczema, Hives Acnes, Boils Color Change Lumps Itching Perpetual hair loss Night Sweats Page 9 of 13

10 Head Headaches Head Injury Migraines Jaw/TMJ Problems Ears Impaired hearing Ringing Earaches Dizziness Nose and Sinuses Frequent colds Nose Bleeds Stuffiness Sinus problems Hayfever Loss of smell Mount and Throat Frequent sore throat Copious saliva Teeth grinding Gum problems Dental cavities Sore tongue/lips Hoarseness Jaw clicks Neck Lumps Swollen glands Goiter Pain or stiffness Respiratory Cough Wheezing Spitting up blood Asthma Pneumonia Emphysema Tuberculosis Sputum Bronchitis Pleurisy Difficulty breathing Shortness of breath Shortness of breath at night Shortness of breath lying down Page 10 of 13

11 Cardiovascular Heart disease Angina High/Low blood pressure Blood clots Phlebitis Rheumatic Fever Swelling in ankles Murmurs Fainting Palpitations/Fluttering Chest Pain Gastrointestinal Trouble swallowing Heartburn Change in thirst Change in appetite Nausea/vomiting Ulcer Abdominal pain or cramps Belching or passing gas Constipation Diarrhea Jaundice (Yellow Skin) Bowel movements How often: Gall Bladder disease Liver disease Hemorrhoids Is there any change? Black stools Blood in stool Urinary Pain on urination Increased frequency Frequency at night Frequent infections Inability to hold urine Kidney stones Musculoskeletal Joint pain or stiffness Arthritis Broken bones Muscle spasm or cramps Weakness Sciatica Blood/Peripheral Vascular Easy bleeding or bruising Anemia Deep leg pain Varicose veins Cold hands/feet Thrombophlebitis Page 11 of 13

12 Male Reproduction Hernias Testicular masses Testicular Pain Venereal disease Are you sexually active? Impotence Herpes Prostate Disease Discharge or sores Gonorrhea Chlamydia Genital warts Syphilis Female Reproduction/Breasts Age of first menses? Date of last annual exam/pap? Length of cycle? Duration of menses? Age of last menses (if menopausal)? Painful menses Are cycles regular Clotting Heavy or excessive flow PMS Symptoms: Endometriosis Ovarian cysts Spotting between cycles Pain during intercourse Discharge Birth control Type: Difficulty conceiving Number of pregnancies Cervical Dysplasia Number of live births Sexual Difficulties Number of miscarriages Herpes Number of abortions Are you sexually active Menopausal symptoms Do you do breast self exams Abnormal PAP Chlamydia Genital warts Syphilis Breast lumps Breast pain/tenderness Nipple discharge Page 12 of 13

13 Is there anything else you would like to comment on? Page 13 of 13