Health Appraisal Questionnaire

Transcription

1 Natural Health Care For The 21st. Century Natural Health Care For The 21st. Century Health Appraisal Questionnaire Natural Health Care For The 21st. Century Natural Health Care For The 21st. Century

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3 Health Appraisal Questionnaire Date: Age DOB SS# Name: Address City State Zip Home Phone Business Cell What is the purpose of your visit and what are your health goals? Circle and list any of the following medications (and doses) you are taking: Antacids Diabetic meds/insulin Cortisone/Anti-inflammation High blood pressure Laxatives Tranquilizers/sleeping pills Chemotherapy Antibiotic/Antifungal Heart medication Aspirin/Tylenol/Other Lithium Recreational drugs Ulcer Oral contraceptives/patch Thyroid Hormone replacement Other Who referred you to our clinic?

4 3 Tulsa Natural Health Clinic Health Appraisal Questionnaire Circle if you eat, drink or use the following. If yes, please give details Alcohol Cigarettes Chew or dip tobacco Coffee/If yes, how many cups per day Tea/If yes, how many glasses per day Cola drinks/if yes, how many per day Luncheon meats Refined sugars Candy Drink tap water Margarine or trans fats Artificial sweeteners (All) Eat at fast food restaurants Eat fried foods Do you diet often / list diets you have been on or are on now Circle if these apply to you. Salt food without tasting Are under excessive stress Do not exercise Exercise (describe) Are you now or have you been exposed to chemicals at home or work Are you now or have you been exposed to second hand smoke List all dental procedures and/or surgeries: indicate year

5 4 Tulsa Natural Health Clinic INSTRUCTIONS: Circle the number which best describes the intensity of your symptoms. If you don t know the answer to a question, leave it blank. 0 = symptom not present 1 = Mild 2 = Moderate 3 = Severe Part 2 Section A: 1. Burping Stomach upsets easily Feel full for extended time after a meal Bloating History of constipation Poor appetite Known food allergies Part 2 Section B: 1. Abdominal cramps Indigestion occurring 1-3 hours after eating Fatigue after eating Lower bowel gas Alternating constipation and diarrhea Diarrhea Mucous in stools Roughage & fiber causes constipation Stool poorly formed Three or more large bowel movements daily Shiny stool Foul smelling stool Dry flaky skin and /or dry brittle hair Left sided pain under rib cage Acne Food allergies Difficulty gaining weight Section C 1. Stomach pains Stomach pains right after and/or before meals Dependency on antacids Chronic abdominal pain Butterfly sensations in stomach Difficulty Belching Stomach pain when emotionally upset or stressed Sudden, acute indigestion Relief of stomach pain by drinking cream or milk History of ulcers or gastritis Currently have an ulcer Black stool when not taking iron supplements Part 2 Section D: 1. Seasonal diarrhea Frequent & recurrent infections (cold, flue, etc.) Vaginal yeast infection Bladder and kidney infections Abdominal cramps Toe and fingernail fungus Alternating diarrhea/constipation Constipation History of antibiotic or steroid use Eat red meat Rapidly failing vision

6 5 Tulsa Natural Health Clinic Part 3 SECTION A: 1. Cannot tolerate greasy food Get headaches after eating Light colored stool Have less than one bowel movement daily Constipation Have hard stool Foul smelling stool Sour taste in mouth Gray colored skin Yellow in whites of eyes Bad breath Body odor Get tired or sleepy after meals Pain in right side under rib cage Difficulty or experience pain when passing stool Retain water (fluid) Big toe is painful Have pain that radiates along outside of leg (s) Dry skin/hair Bright red or dark blood in stool No Yes (10) 21. Have had jaundice or hepatitis (A-B-C) No Yes 22. High cholesterol-elevated LDL No Unknown Yes (10) 23. Elevated triglycerides No Unknown Yes (10) Part 3 SECTION B: 1. Swollen bulging eyes Strong smelling urine Thick skin and or finger nails Dry skin Sensitive to the cold Cold hands or feet Excessive menstrual bleeding Chronic fatigue Difficulty waking in the mornings Fell depressed or apathetic Low or decreased sex drive Puffy, wrinkly skin Eating sugar causes irritability or mood swings PMS Constipation Thinning or loss of outside portion of eyebrow Gain weight easily Anemia unaffected by taking iron Axillary (underarm temp below 97.6 for 7-10 days) Slow reflexes Infertility Part 4 SECTION A: 1. Sensitive to exhaust fumes, smoke, smog, petrochemicals Periodic constipation Cannot tolerate much exercise Depression or rapid mood swings Dark circles under the eyes Experience dizziness when standing or standing quickly Get colds easily with weather changes Headaches Exercise makes you feel worse

7 6 Tulsa Natural Health Clinic Part 4 SECTION A continued 9. Difficulty breathing Water (fluid) retention Eyes are sensitive to the sun or bright lights Occasionally feel weak or shaky SECTION B: 1. Inflamed or bleeding gums Running nose Get boils or styes Nose bleeds Throat infections Cold sores, fever blisters Loss of smell Loss of taste Wounds, cuts heal slowly Hair falls out Swollen lymph glands Ear infections Hair grows slowly Slow to recover from colds or flu Catch colds or flu easily SECTION C: 1. Itching of nose or eyes Itching of roof of mouth or throat Migraine headaches Entire body aches, painful to touch Swollen joints Food sensitivity or allergies Certain foods make you feel sick, depressed or jittery Chronic pain Painful stomach or intestines Alternating constipation and diarrhea Mucous in throat Post nasal drip Discharge from eyes Watery eyes Puffiness or dark circles under the eyes Ears discharge or ears stuffed up Nasal congestion Runny nose Breathe through mouth Wheezing Difficulty swallowing Sneezing Hyperactivity Chronic lung congestion Use aspirin, Tylenol, ibuprofen regularly Skin rashes Part 5 SECTION A: 1. Difficulty breathing Chest pain while walking Heaviness in legs Calf muscles cramp while walking Heart pounds easily Feel jittery Heart misses beats or has extra beats

8 7 Tulsa Natural Health Clinic Part 5 SECTION A continued 8. Swelling of feet and ankles Rapid beating heart Heartburn after eating Pain in left arm Exhausted with minor exertion Do you drink more than 5 cups of coffee daily? Yes No 14. Have you ever been diagnosed with heart trouble? Yes No Part 5 SECTION B 1. Cold hands and feet Slurred speech Calf muscles cramp while walking Headaches Numbness in extremities Poor concentration Ringing in ears Hair in ear canal? Tingling or burning in hands or feet? Spider vein on nose and or face Part 5 SECTION C: 1. Pain when getting up in morning in back of head and neck Dizziness Blushing with no apparent cause High blood pressure Part 6 SECTION A: 1. Experience dizziness when standing quickly Loss of vision when standing quickly Crave sweets Headaches relieved by eating sweets or consuming alcohol Feel shaky or jittery Irritable if a meal is missed Wake up in middle of night craving sweets Feel tired or weak if a meal is missed Heart palpitations after eating sweets Need to drink coffee or tea to get started Impatient, moody or nervous Feel tired 1 to 3 hours after eating Poor memory Feel faint Poor concentration Forgetful Feel calmer after eating a meal Part 6 SECTION B: 1. Night sweats Lowered resistance to infection Increased thirst Fatigue Boils and leg sores Lesions, cuts take a long time to heal Overweight Feel better after exercise Failing eyesight Crave sweets, but eating sweets does not relieve symptoms Family history of diabetes Sugar in urine Skin tags

9 8 Tulsa Natural Health Clinic Part 7 1. Chest pain Chronic cough Difficult breathing Coughing up blood Pain around ribs Shortness of breath Coughing up phlegm Rattling mucous when you breathe Sensitive to smog Infection settles in lung Live or work around people who smoke Bronchitis No Yes (10) 13. Exposed to chemicals and radiation No Yes (6) 14. Smoker or ex-smoker No Yes (6) Part 8 1. Frequent urination Frequent bladder infections Rarely need to urinate Urination when you cough or sneeze Painful/burning when passing urine Difficulty passing urine Dripping after urination Can t hold urine Rose colored urine (bloody urine) Cloudy urine Strong smelling urine Back or leg pains associated with dripping after urination History of kidney or bladder infection Have you used antibiotics for urinary tract infections? Back pain in the kidney region? General water retention Part 9 (Males Only) SECTION A: 1. Difficulty urinating A sense of bladder fullness Increased straining with smaller amounts of urine passed Rose colored (bloody) urine Pain or burning while urinating Wake up to urinate at night Dripping after urination Pain or fatigue in the legs or back Decrease sex drive Ejaculation causes pain SECTION B: 1. Difficulty attaining and/or maintaining an erection Low sex drive Premature ejaculation Pain/coldness in genital areas Infertile No Yes (6) 6. Varicose vein on scrotum Low sperm count No Yes (6) SECTION C: 1. Discharge from penis Past or present rash on penis Swollen genitals Swelling in groin Venereal disease No Yes (9)

10 9 Tulsa Natural Health Clinic Part 10 (Females - only if menstruating) SECTION A: Circle if you experience any of these symptoms within 10 to 14 days prior to menstruation. (Section A only) 1. Monthly weight gain Depression Moodiness/irritability Bloating and/or vomiting Nausea and/or vomiting Suicidal feeling No Yes (10) 7. Anxiety Leg cramps and tenderness Asthma attacks Headaches Easily distracted Anger Tender breasts Low backache Other SECTION B: 1. Vaginal itching Vaginal discharge Low or no desire for sex Dislike for intercourse Missed periods Over 15 years of age and have not begun menstruation Part 10 SECTION B Cont. (Females only) 7. Unable to get pregnant No Yes 8. Miscarriages No Yes How many? 9. Abortion No Yes How many? Part 10 SECTION C: Check if you experience any of these symptoms DURING MENSTRUATION. 1. Low abdominal pain Dull ache radiating to low back or leg Increased urinary frequency Pelvic soreness Diarrhea Headaches Abdominal bloating Menstrual pain Nausea and/or vomiting Have to lie down on first or 2 day of period Craving for sweets Insomnia Light scanty blood flow Pain and cramps without blood flow Heavy menstrual bleeding Anxiety about menstrual cycle Pain during period is progressively getting worse with time Part 10 SECTION D: 1. Vaginal bumps and sores Pubic area sore Ovarian cysts Uterine cysts Pain in ovaries Breast lumps Breast sore to touch

11 10 Tulsa Natural Health Clinic Part 10 SECTION D: continued 8. Breast painful Water retention Swollen feeling Premenstrual breast pain or discomfort Mother used D.E.S. (hormones) while pregnant No Yes 13. Abnormal PAP smear No Yes (15) 14. Family history of breast cancer No Yes (10) 15. Form of birth control Part 10 SECTION E: 1. Hot flashes Night sweats Hysterectomy No Yes 4. Depression/mood swings Insomnia Craving for sweets Heavy bleeding two weeks/month Sweating throughout the day Dryness of skin, hair, and vagina Painful intercourse Vaginal pain Vaginal itching Osteoporosis Part 10 SECTION F: HORMONE BALANCE TEST SYMPTOM GROUP 1 PMS Early miscarriage Unexplained weight gain Anxiety Insomnia Painful and or lumpy breasts Cyclical headaches Infertility Total boxes checked If you have checked 2 or more boxes in this group, turn to answers to find out what type of hormonal imbalance you may have SYMPTOM GROUP 2 Vaginal dryness Painful intercourse Bladder infections Hot flashes Night sweats Memory problems Lethargic depression Total boxes checked If you have checked two or more boxes in this group, turn to answers to find out what type of hormonal imbalance you may have. SYMPTOM GROUP 3 Rapid weight gain Mood swings Anxious depression Red flush on face Weepiness (crying) Cervical dysplasia (abnormal pap smear) Breast tenderness Heavy bleeding Migraine headaches Foggy thinking Gallbladder problems Total boxes checked If you have checked two or more boxes in this group, turn to answers to find out what type of hormonal imbalance you may have. SYMPTOM GROUP 4 A combination of the symptoms in #1 and #3 Total boxes checked SYMPTOM GROUP 5 Acne Excessive facial and arm hair Thinning hair on head Ovarian cysts Polycystic ovary syndrome (PCOS) Hypoglycemia and/or unstable blood sugar Infertility problems Mid-cycle pain Total boxes checked If you have checked two or more boxes in this group, turn to answers to find out what type of hormonal imbalance you may have.

12 11 Tulsa Natural Health Clinic SYMPTOM GROUP 6 Debilitating fatigue Foggy thinking Thin and/or dry skin Brown spots on face Unstable blood sugar Low blood pressure Intolerance to exercise Total boxes checked If you have checked two or more boxes in this group, turn to answers to find out what type of hormonal imbalance you may have. ANSWERS TO HORMONE TEST 1. SYMPTOM GROUP 1 Progesterone deficiency: This is the most common hormone imbalance among women of all ages. You may need to change your diet, ask your doctor about getting off of synthetic hormones and you may need to use some progesterone cream. 2. SYMPTOM GROUP 2 Estrogen deficiency: This hormone imbalance is most common in menopausal women; especially if you are petite and/or slim. You may need to make some special changes to your diet; take some women s herbs; and some women may even need natural estrogen. 3. SYMPTOM GROUP 3 Excess estrogen: In women, this is most often solved by getting off of the conventional hormones (with your primary care physicians approval) most often prescribed by doctors for menopausal women. 4. SYMPTOM GROUP 4 Estrogen dominance: This is caused when you don t have enough progesterone to balance the effects of estrogen. Thus, you can have low estrogen but if you have even lower progesterone, you can have symptoms of estrogen dominance. Many women between the ages of 40 and 50 suffer from estrogen dominance. 5. SYMPTOM GROUP 5 Excess androgens (male hormones): This is most often caused by too much sugar and simple carbohydrates in the diet and is often found in women who have polycystic ovary syndrome (PCOS) 6. SYMPTOM GROUP 6 Cortisol deficiency: this is caused by tired adrenals, which is usually caused by chronic stress. If you are trying to juggle a job and a family, chances are pretty good you have tired adrenals. We highly recommend in each case getting a comprehensive saliva test. "24 HOUR COMPREHENSIVE CIRCADIAN ENDOCRINE PROFILE" Why Saliva? Saliva collection is simple, non-invasive, and can be performed in the privacy of ones home. The sample is sent by mail to the laboratory. The results will be sent to the individual or the referring practitioner within ten working days following the receipt of the sample(s). The hormones are stable at room temperature for up to five days and require no further handling for shipment. Saliva is considered to be a better indicator of biologically active hormone levels than blood - more accurately reflecting the body's functional hormonal status. Over 20 years of research has proven the effectiveness of using saliva (instead of serum or urine) as a diagnostic medium to measure the "free" (unbound) bioavailable fraction of circulation hormones. Saliva testing provides a simple non-invasive means of determining if hormone levels are within the expected normal range for one's gender and age. It is also an accurate method of evaluating how hormone replacement therapy, topical hormone creams, sublingual drops, diet, herbal therapy and exercise influence these levels. The following 10 saliva tests are performed in this Comprehensive 24 hour Circadian Endocrine Profile. The collection kit (EndoScreen ) is FDA registered and approved. Cortisol "Adrenal Stress" Testing "The root to balancing hormones starts with adrenal support." The Adrenal Stress panel provides a reliable stress marker, revealing adrenal imbalances. Changes in circulating levels of cortisol and DHEA-SO4 indicate shifts in adrenal function that can affect an individual's energy, disease resistance, and emotional state. The adrenal hormones, cortisol and DHEA-SO4, are directly involved in the body's growth, immune response, and cardiovascular function. Cardiovascular disease, chronic fatigue, depression, and osteoporosis are some of the conditions that result from adrenal hormone imbalance. They affect carbohydrate, protein and lipid metabolism, act as anti-inflammatory agents, modulate thyroid function, and help in stress related conditions. For the first time in history, this innovative saliva test employs cutting edge twenty-first century technology with the ancient wisdom of Chinese Medicine. Comprehensive Panel Includes the following Hormones: Cortisol DHEA Progesterone Estradiol Testosterone Testing includes 6 cortisol saliva tests 1) Body Clock Relationship to testing times according to the Five Element Theory of Chinese Medicine. Body Clock 2) The actual specimen time corresponds to an organ, gland & adrenal function. 3) A Neuro-Emotional Remedy will be recommended for each organ related to An abnormal test time result.

13 12 Tulsa Natural Health Clinic DHEA Sample time: Midnight Progesterone Sample time: 8 p.m. NOTE: If you have had a blood hormone or recent saliva hormone test, please bring results with you. Estradiol Sample time: 8 p.m. Testosterone Sample time: 8 p.m. Part 11 SECTION A: 1. Painful fingers Bones sore/painful Eat red meat Cavities Arthritis Drink carbonated beverages/soda cans per week Yes 7. Gum disease Bone loss Calcium deposits Use antacids Dentures Bone deformity Have you been diagnosed with osteoporosis or other bone Diseases Recent bone fracture or break Postmenopausal Part 11 SECTION B: 1. Muscle spasms Tightness in shoulder muscles Muscle cramps Leg cramps at night Stiff all over Stiff in the morning Unable to sit up straight Pain in neck and or shoulders Back pain Part 11 SECTION C 1. Over flexible joints (double jointed) Back pain Swollen knees Athletic injury Bursitis Tendonitis Joint pain Slipped disc No Yes (5) 9. Herniated disc No Yes (10) 10. Loss in height No Yes 11. Injure easily No Yes 4. Pain in arms, hands

14 13 Tulsa Natural Health Clinic Part Head feels heavy Light headedness/fainting Loss of balance Dizziness Ringing/buzzing in ears Trembling hands Loss of feeling in hands and/or feet (toes) Exhaustion on slightest effort Limbs feel too heavy to hold up Loss of grip strength Tingling pain sensation Convulsions Incoordination Nervousness Accident prone Loss of muscle tone Need for hours of sleep Have had shingles Part Nightmares Can t fall asleep Intense dreams Leg cramps/restless legs Restless, uneasy sleeper Wake frequently through night No Yes 7. Wake up in the middle of night, can t fall back to sleep No Yes 8. Sleep walk No Yes Part 13B (Sleep Apnea) Sleep apnea is a common disorder. Experts say it affects about eighteen million Americans. People with sleep apnea stop breathing for brief periods while they sleep. They may awaken for a few seconds as they struggle to breathe. The next day, the sleeper may not remember what happened. Signs of the disorder include sleepiness during the day and restless sleep. Some people make rough sounds while they sleep. More men have sleep apnea than women do. It is also common in older adults and in persons who are heavy. Circle the numbers of the comments that apply to you. 1. I have been told that I snore. 2. I sometimes suffer from daytime sleepiness. 3. I have dozed off in church on occasion. 4. If I doze off, I sometimes wake up with a "snort." 5. I have been told that I hold my breath or stop breathing in my sleep. 6. I have high blood pressure. 7. I toss and turn a lot in my sleep. 8. I get up to visit the bathroom more than once a night. 9. I often feel sleepy and struggle to stay alert, especially during the afternoon 10. I sometimes fall asleep while watching TV. 11. I have fallen asleep at a stop light or stop sign. 12. I have actually fallen asleep while driving. 13. I wish I had more energy and less fatigue. 14. My neck measures over 17 inches (males) or over 16 inches (females) 15. I am more than 15 pounds overweight. 16. I seem to be losing my sex drive, or my ability to perform in bed. 17. I sometimes get heartburn in the middle of the night. 18. I frequently wake with a bad taste in my mouth, or a dry mouth and throat. 19. I often get morning headaches. 20. When I cannot wake up from a nightmare, I feel paralyzed and I panic.

15 13A Tulsa Natural Health Clinic 21. I suddenly wake up gasping for breath. 22. I sometimes wake up with a pounding or irregular heartbeat. 23. I frequently feel depressed. 24. I feel as if I'm getting old too fast. 25. My friends and family say I'm sometimes grumpy and irritable. 26. I have short term memory problems. 27. I don't feel rested or refreshed, even after 8 or 10 hours of sleep. 28. I sometimes perspire a lot, especially at night. 29. I'm tired all the time. 30. I have great difficulty concentrating. If you circled 5 or more symptoms, you could have OSA (obstructive sleep apnea). The risks of OSA include heart attacks, strokes, impotence, irregular heartbeat, high blood pressure and heart disease. Take this form to your doctor. Treatments are available to eliminate apneas and snoring without surgery or drugs, but you must visit a sleep center or clinic to be tested. Part 14 (Acid/base imbalance) 1. Fatigue Cold hands and feet Headaches Allergies Acne Bloating Rapid breathing Irritability Candida or fungal infections Depression and anxiety Cold sores Urinary tract infections Arthritis Excess stress Difficult weight loss Constipation Rheumatic conditions Insomnia Gastric and stomach problems Water retention low 6-9 moderate high Part 15 DENTAL RECORD & METAL ALLERGIES This extensive Q&A gives us a preliminary indication of whether you may suffer with a metal allergy. 1. YOUR DENTAL RECORD Dental restorations are the most common cause of metal allergy; the more intimate exposure to metals such as mercury and gold, the greater the chance of becoming sensitized. NOTE: If you don t know the answer to a specific question, place a? 1.1 CURRENT DENTAL FILLINGS (if your not sure, please ignore) Dental Material Year of placement: Number of fillings: Amalgam Gold Titanium Composites Metal-bound ceramic Cobalt-crown Non-metallic ceramic 1.2 ROOT FILLINGS Amalgam Gutta-percha Calcium hydroxide Other

16 T u l s a N a t u r a l H e a l t h C l i n i c W a r r e n M e d i c a l B l d g S. Yale, Ste. 804 Tulsa, OK F A X : d r p a u t u l s a n a t u r o p a t h d o c. c o m