ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No
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- Philomena Ariel Chambers
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1 ADULT HEALTH HISTORY Name Date Address City State Zip code Phone, please circle your preferred number: (home) (cell) (work) Yes No (if you would like appointment reminders) May we you a monthly newsletter and/or other educational materials? Yes No Age Date of birth Gender female male Occupation Hours per week Retired Years Employer Social Security # Married Partnership Single Separated Divorced Widowed Live with: Spouse or partner Parents Children Friends Alone How did you hear about our clinic? If you were referred here, please let us know so that we can thank them. If internet: Google Other sites (please specify) Has any other family member already been a patient at the clinic? Next of kin or other to reach in case of emergency: Relationship Phone Address
2 CONTEXT OF CARE REVIEW Successful health care and preventive medicine are only possible when the health care provider has a complete understanding of the patient physically, mentally, and emotionally. Your time, thoughtfulness and honesty in completing this overview will greatly aid us in helping you reach your health goals. What three expectations do you have from this visit to our clinic? What long term expectations do you have from working with our clinic? What expectations do you have of us personally as your physician(s) / health care provider(s)? What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Rate from 0 to 10, with 10 being 100% committed) 0% % What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive? Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making?
3 LIFE OF WELLNESS Wellness is a balance of many factors. Using the circle to your right, indicate your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, write in 100% for career. Do the same for each area of the chart. Are you currently receiving health care? Y N If yes, where and from whom: If no, when and where did you last receive medical or health care? What was the reason? What are your most important health problems? List as many as you can in order of importance: 1) 2) 3) 4) 5) Do you have any known contagious diseases at this time? Y N If yes, what?
4 FAMILY HISTORY Do you have a family history of any of the following (please circle)? Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Epilepsy Arthritis Glaucoma Tuberculosis Stroke Anemia Mental Illness Asthma/Hayfever/Hives Any other relevant family history? What is your heritage: HOSPITALIZATIONS/SURGERY/IMAGING What hospitalizations, surgeries, X-Rays, CAT Scans, EEG, EKG s have you had? ALLERGIES Are you hypersensitive or allergic to... Any drugs? Any foods? Any environmental factors or chemicals? CURRENT MEDICATIONS Laxatives Y N Pain relievers Y N Antacids Y N Cortisone Y N Appetite suppressants Y N Antibiotics Y N Tranquilizers Y N Thyroid medication Y N Sleeping pills Y N Please list any prescription medications, over the counter medications, vitamins and/or other supplements you are taking? 1) 7) 2) 8) 3) 9) 4) 10) 5) 11) 6) 12)
5 GENERAL Height: Weight: lbs. Weight 1 year ago: lbs. Maximum Weight: When during the day is your energy the best? Main interests and hobbies: When: worst? Exercise: Y / N If so, what kind? How often / week? Watch TV: Y / N If so, how many hours / week? Read: Y / N If so, how many hours / week? Do you have a religious or spiritual practice? Y N TYPICAL FOOD INTAKE IN THE LAST WEEK Breakfast: Lunch: Dinner: Snacks: To drink: If yes, what? FOR THE FOLLOWING, PLEASE CIRCLE Y = a condition you have now N = Never had P = Problem in the past S = Sometimes a problem now GENERAL Do you sleep well? Please circle, or shade in the area on the Average 8 hours? diagram below where you may be Awake rested? experiencing pain. Have a supportive relationship? Have a history of abuse? Experienced a major trauma? Drink soda? Use recreational drugs? Treated for drug dependence? Drink alcoholic beverages If so, how many per week? Treated for alcoholism? Use tobacco? If in the past, how many years? How many packs per day? Do you enjoy your work? Take vacations? Spend time outside? Eat three meals per day? Do you go on diets often? Do you eat out often? Do you drink coffee? Drink black/green tea?
6 Please rate each of your current symptoms, from 0 to 3 (3 = worst). GAN Irritability / frustration / impatient Depression / high stress Emotional eating Unfulfilled desires Visual problems / floaters Blurred vision / poor night vision Red / dry / itchy eyes Headaches / migraines Dizziness Feeling of lump in throat Muscle twitching / spasms Neck / shoulder tension Jaw clenching / grinding Brittle nails Sighing Sensation or pain under rib cage PMS Genital itching / pain / lesions XIN Palpitations Chest pain / tightness Insomnia / sleep problems Mood swings Anxiety Restless / easily agitated Vivid dreams Lack of joy in life Forgetful Aversion to heat Bitter taste in mouth Tongue / mouth ulcers / cankers SHEN Low energy Frequent urination Urinary tract infections Lack of bladder control Wake to urinate Feel cold easily Cold hands / feet Night sweats / hot flushing Low sex drive High sex drive Thyroid imbalance Loss of head hair Hearing problems Crave salty food Fear Poor long term memory Ankle swelling Tinnitus FEI Dry cough Cough with phlegm Nasal discharge / drip Sinus infection / congestion Itchy / painful throat Dry mouth / throat / nose Skin rashes / hives / eczema Snoring Grief / sadness Shortness of breath Allergies / asthma Weak immune system PI Heaviness in the head / body Fatigue after eating Difficulty getting up in morning Water retention Muscles tired / weak Bruise easily Unusual bleeding (stool, nose, etc) Bad breath Poor appetite Increased appetite Crave sweets Poor digestion Nausea / vomiting Bloating / gas Hemorrhoids Constipation Loose stool Alternate constipation / loose Intestinal pain / cramping Heartburn Pensive / over-thinking
7 PI (CONT D) Overweight Foggy mind Yeast infections Aversion to cold Cold nose Increased thirst Prefer warm / cold drinks Sweats easily Y = a condition you have now N = Never had P = Problem in the past S = Sometimes a problem now FEMALE REPRODUCTIVE MALE REPRODUCTIVE Age of first menses: Age of last menses (if menopausal): Length of cycle: Duration of menses (flow): Are your cycles regular? Painful menses? Heavy or excessive flow? PMS? Symptoms: Bleeding between cycles? Clotting? Endometriosis? Ovarian cysts? Vaginal odor? Vaginal discharge? Date of last PAP smear? Abnormal PAP? Cervical dysplasia? Are you sexually active? Sexual orientation: Birth control? Type: Current/past birth control, how long? Pain during intercourse? Sexually transmitted infections? Difficulty conceiving? Number of pregnancies: Number of live births: Number of miscarriages: Number of abortions: Do you do self breast exams? Breast pain/tenderness? Breast lumps? Nipple discharge? Menopausal symptoms? days days Are you sexually active? Sexual orientation: Birth control? Type: Discharge or sores? Sexually transmitted infections? Hernias? Testicular masses? Testicular pain? Prostate disease? Impotence? Premature ejaculation?
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SHEILA WOLFSON, M.Ed., C.N.S. Nutritionist and Health Counselor. 20 Main Street, Suite 300, Natick, MA Phone/Fax (508)
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Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
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Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History
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What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
If you have any questions, feel free to contact us at 475- WLNS (9567) or
UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH
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Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
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LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician