Patient Health History
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- Warren Lynch
- 5 years ago
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1 Name: (first) (middle) (last) Patient Health History Home Phone: Cell Phone: Work Phone: Date: / / address: Please Contact me at: ( ) Home, ( ) Cell, ( ) Work Date of Birth: / / Age: Gender: M/F Marital status: S M D W Occupation: SSN: Street Address: City/State: Zip: Referred By: Family Physician: Insurance Carrier:(optional) Policy #: Have you ever experienced acupuncture before? Are you willing to take Chinese Herbs if prescribed by your practitioner? Yes or NO In Case of Emergency, Contact: Phone:
2 Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank you. 1. When and where did you last receive health care? For what reason? 2. Has your case been referred to an attorney? Y N 3. Please identify the health concerns that have brought you to Healing Traditions Oriental Medicine Clinic in order of importance below: Condition Past Treatment a. How does this condition affect you? b. How does this condition affect you? c. How does this condition affect you? d. How does this condition affect you? 4. If applicable, please list any foods, drugs, or medications you are hypersensitive or allergic to (please include reaction): 5. Please list any medications (prescribed and over-the-counter), vitamins, and supplements you are currently taking: (or bring in a separate list, if the lines provided below don t provide you with enough room) 6. Do you have any reason to believe you may be pregnant? Y N If so, how far along are you? 7. Do you have any infectious diseases? Y N If yes, please identify:
3 8. Family History: Father Mother Brothers Sisters Spouse Children Check ( ) those applicable: Age (if living) Health (G=Good, P=Poor) Cancer Diabetes Heart Disease High Blood Pressure Stroke Mental Illness Asthma/Hay fever/hives Kidney Disease Age (at death) Cause of Death 9. Height: Weight: Currently: Past Maximum: When? 10. Blood Pressure: What is your most recent blood pressure reading? / When was this reading taken? 11. Childhood Illness (please circle any that you have had): Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles German Measles Chicken Pox 12. Immunizations (please circle any that you have had): Polio Tetanus Rubella/Mumps/Rubella Pertussis Diphtheria Hib Hepatitis B Others: 13. Hospitalizations and Surgeries: Reason When Reason When
4 14. X-Rays/CAT Scans/MRI s/nmr s/special Studies: Reason When Reason When 15. Emotional (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Mood Swings Mental Tension Depression Irritable Nervousness Anxiety Anger/Frustration Grief Lack of Motivation Please Describe All Diagnosed Psychiatric or Mood Disorders: 16. Energy and Immunity (Circle any that you experience NOW and Underline any that you have experienced in the PAST): Fatigue Slow Wound Healing Chronic Infections Chronic Fatigue Syndrome Autoimmune Disease Multiple Sclerosis Lupus Fibromyalgia Clotting Disorders Other Autoimmune or Energy Problems: 17. Head, Eye, Ear, Nose, and Throat (Circle any that you experience NOW and Underline any that you have experienced in the PAST): Impaired Vision Eye Pain/Strain Floaters in Vision Glasses/Contacts Glaucoma Tearing/Dryness Impaired Hearing Ear Ringing Earaches Headaches/Migraines Sinus Problems Nose Bleeds Frequent Sore Throats Teeth Grinding TMJ/Jaw Problems Teeth problems Hay Fever Dizziness Recurrent Sore throat 18. Respiratory (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Frequent Common Colds Chronic Allergies Difficulty Breathing Asthma Shortness of Breath Bronchitis Persistent Cough Production of Phlegm Chest Pain Pain w/ Deep inhalation Coughing up blood Pneumonia Pleurisy Emphysema Tuberculosis Other Respiratory Problems:
5 19. Cardiovascular (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Heart Disease/CVD Chest Pain Swelling of Ankles High Blood Pressure Low blood pressure Palpitations/irregular Heart beat Stroke Heart Murmurs Rheumatic Fever Varicose Veins Phlebitis Dizziness Cold hands & feet Blood clots Clotting Disorders History of Fainting difficulty breathing Other Cardiovascular Problems: 20. Gastrointestinal (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Ulcers Changes in Appetite Loss of Appetite Nausea/Vomiting Epigastric Pain Passing Gas Heartburn Belching Indigestion Gall Bladder Disease Liver Disease Hepatitis B or C Hemorrhoids Abdominal Pain Diarrhea Constipation Black Stools Bad Breath Blood in Stools Rectal Pain Chronic Laxative use Other Problems w/gastrointestinal tract: 21. Genito-Urinary Tract (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Kidney Disease Painful Urination Impaired Urination/Difficulty Urinating Frequent Urinary Tract Infections Frequent Urination Urgency to urinate Heavy Urinary Flow Kidney Stones Blood in Urine Pain in Genitals Do You wake-up at night to urinate? if so, How many times/night? Any particular color to Urine? Unable to hold Urine Impotence Sores on genitals Any lower leg Swelling? Y N If yes, is the swelling: Mild Moderate Severe Other Problems with your genital or urinary functions:
6 22. Female Reproductive/Breasts (Circle any that you experience NOW and Underline any that you have experienced in the PAST): Irregular Cycles Bleeding Between Periods Heavy Flow Light/Scanty flow Absence of flow? If yes, for how long? Describe Color of Flow Clotting Painful Periods Mid-Cycle Pain Excess Vaginal Discharge Premenstrual Problems? If Yes, Please Explain: First day of last Menses: Length of time between menses: Duration of Period Flow (# of Days Flowing) Breast Tenderness Breast Lumps Nipple Discharge Low Libido High Libido Difficulty Conceiving? If yes, Please Explain: Assisted Reproductive Technology (ART) Treatment: Yes or No If you answered yes to ART Treatment and or to Difficulty Conceiving, Please download, print, and fill out the Fertility Intake Form and Fertility Treatment History Form found on our website: found on the Patient Form Downloads page under General Info in the menu bar. Thank you. Menopausal Symptoms Hot Flashes Night Sweating Onset (age) of Peri-Menopause/Menopause Symptoms: Hysterectomy: Full or Partial Reason for Hysterectomy:
7 23. Menstrual/Birthing History: Age of First Menses: # of Pregnancies: # of Live Births: # of Miscarriages: # of Abortions: Currently Taking Birth Control? Yes or No If Taking Birth Control, Please Describe what Type (ie: Pill, IUD, etc.) & Your Birth Control History: 24. Male Reproductive (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Sexual Difficulties Prostrate Problems Testicular Pain/Swelling Penile Discharge Impotence/Erectile Dysfunction Low Libido High Libido Other: 25. Musculoskeletal (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Neck/Shoulder Pain Muscle Spasms/Cramps Arm Pain Hand/Wrist Pain Upper Back Pain Mid Back Pain Low Back Pain Leg Pain Knee Pain Foot/Ankle Pain Joint Pain (if so, where?): Joint Swelling (if so, Where?): 26. Neurologic (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Vertigo/Dizziness Paralysis Numbness/Tingling. If so, Where Loss of Balance Seizures/Epilepsy Concussion Dizziness Poor Memory Depression Anxiety Lack of coordination Any diagnosed Neurologic diseases/conditions:
8 27. Endocrine (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Hypothyroid Hyperthyroid Hypoglycemia Type I Diabetes Type II Diabetes Feeling Hot or Cold Night Sweats Other Endocrine Problems: 28. Other (please Circle any that you experience NOW and Underline any that you have experienced in the PAST): Anemia Cancer Rashes Eczema/Hives Cold Hands/Feet Is there anything else we should know? 29. Lifestyle: Do you typically eat at least three meals per day? Y N If no, how many? Please describe your average daily diet Please Circle if you are: Vegetarian or Vegan Approximately How Many glasses or Ounces of Water do you drink per day? Approximately How many glasses of Caffeinated beverages do you drink per day? Approximately How many glasses of carbonated beverages do you drink per day? Temperature Preference of Beverages (ie: Iced, Cold, Room Temperature, Warm) Nicotine/Alcohol/Caffeine Use: Exercise routine: Spiritual practice: How many hours per night do you sleep? Do you wake rested? Y N Level of education completed: High School Bachelors Masters Doctorate Other Occupation: Employer: Hours/Week: Do you enjoy work? Y N Why/Why not?
9 NCCAOM Certified Dipl. O.M., FABORM Have you experienced any major traumas? Y N Explain: Television habits: Reading habits: Interests and hobbies:
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CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form
Ayurvedic Intake Form
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Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History
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I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION
PERSONAL INFORMATION NAME: TODAY'S DATE: ADDRESS HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: PHONE: HOME MOBILE WORK EMAIL ADDRESS: EMERGENCY CONTACT: STATUS: SINGLE MARRIED DIVORCED WIDOWED OTHER: NUMBER
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Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
Patient History (Please Print)
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Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Health Questionnaire. Name: Age: Marital Status: Nationality: Occupation: Address: Telephone: (home) (work)
Vitality for Life HEALTH CENTER 560 Bryne dr. Unit 1A Barrie, ON L4N 9P6 705.733.2033 www.vitalityforlife.ca Health Questionnaire Name: Age: Last Name First Name Birthday: / / Sex: M F day/month/year Marital
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
Blake Acupuncture & Herbal Medicine 16 Bradlee Road Medford, MA
Please complete this Health History Form. You may email it back to the clinic (LBlakeLac@gmail.com) or print it out and bring it with you to your appointment. Thank You. Name: Date: Address: Phone (day):
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
PATIENT HEALTH INFORMATION SHEET
. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
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