Debra Gibson, N.D. 132 East Putnam Avenue, Suite L Cos Cob, CT Tel: (203)

Transcription

1 PATIENT INFORMATION Date Laboratory preferred by Insurance (Quest, Lab Corp, other) Name Age Sex Address Birth date City State Zip Phone (home) (work) (cell) Occupation Married Divorced Single Widowed Civil Union Life Partner Next of kin, or other emergency contact Address Phone: How were you referred to the office? Note: In order to maintain the highest quality of personal service at the most reasonable cost, we ask that payment be made with each visit. Many Connecticut insurance companies cover care by a naturopathic physician;; your receipt for payment from this office contains the information required for processing of your claim, and should be submitted with your claim form. FEE SCHEDULE First Visit- $ (up to one hour) Initial visits requiring more than one hour will be prorated based on this hourly rate. Regular Office Visits - $280.00/ hour 15 minutes - $ minutes - $ minutes - $ Telephone consultations are subject to same fees as office visits. Failure to notify us one business day (2 business days for new patients) in advance of appointment change/cancellation will result in a charge. Debra Gibson, N.D. 132 East Putnam Avenue, Suite L Cos Cob, CT Tel: (203) drgibsonsoffice@sbcglobal.net

2 HEALTH PROFILE 2 Holistic/preventive health care is possible only with the aid of a complete picture of the patient physically, mentally and emotionally. Please help by carefully and thoroughly completing this health history questionnaire. Print all information and mark any questions you do not understand with a question mark. What health problems do you want to talk about today? List them in order of importance. 1) 2) 3) 4) In your opinion, what are your most important health problems? List as may as you can in order or importance. 1) 2) 3) 4) 5) 6) 7) 8) Past Medical History: The general state of my health has been Excellent Good Fair Poor What childhood illnesses have you had? Rubella (3 day measles) Measles (2 week) Whooping cough Asthma Rheumatic fever Mumps Chickenpox Scarlet fever Polio Other What immunizations have you had? 1) 2) 3) 4) Did you have any bad reactions? When and where did you last receive medical or health care? For what reason?

3 YOUR HEALTH HISTORY 3 NOW PAST NEVER NOW PAST NEVER Alcoholism Heart Murmur Anemia High Blood Pressure Arthritis Injury (Serious) Asthma Pneumonia Cancer Thyroid Trouble Colitis Tuberculosis Diabetes Sexually Transmitted Disease (STD) Substance abuse Emotional/Mental Illness Emphysema Migraine Headaches Gout Rheumatism Kidney Disease Obesity Hepatitis/Liver Uncontrolled bleeding Disease Ulcers Hospitalizations? (List as best you can) Type of illness/operation: Date Where Have you had any X-Rays taken? Type of X-Ray Date Where What medicines do you take? (Include nutritional supplements, herbs and non-prescription items.) **Please bring nutritional/ herbal supplement bottles with you to your appointment.

4 4 Are you allergic to any medicines or other substances? YES NO If yes, please list: What happens when you have an allergy attack? FAMILY HISTORY Please list ages and, if deceased, what the cause of death was and at what age: Grandfather (mother s side) Grandmother (mother s side) Mother Sisters Grandfather (father s side) Grandmother (father s side) Father Brothers Has any BLOOD RELATIVE had any of the following? Yes No D.K. (Don t know) Yes No D.K. Alcoholism/ Hay Fever Substance Abuse Anemia Heart Attack Arthritis High Blood Pressure Asthma Seizure or Epilepsy Bleeding (easily) Sickle Cell Anemia Cancer Stroke Diabetes Thyroid Trouble Eczema Tuberculosis (TB) Gout Glaucoma

5 ` 5 SOCIAL HISTORY Military Service: When? Where? Symptoms Please mark 1 (mild), 2 (moderate) or 3 (severe) if any of the following apply to you now or in the past. Integument NOW PAST skin rough, dry, scaly, bumpy, itch (circle) rashes, warts, moles, cysts (circle) light or dark patches of skin (circle) increased hair growth in unusual places hair loss pimples color changes in nails ridges, pits or spots on nails hives Hematopoietic, Lymphatic, Immune wounds heal slowly difficulty stopping bleeding anemia bleeding from unusual places swollen glands bruise easily frequent colds, coughs, infections

6 NOW PAST NOW PAST 6 Endocrine increased thirst weakness unexplained weight loss/gain chronic fatigue prefer hot weather increased hunger prefer cold weather can t stand heat cold hands or feet can t stand cold Head dizziness double vision severe or chronic headache fainting spells seizure or fits Eyes poor eyesight (near or far-sighted) light hurts eyes eyes excessively dry or tearing poor night vision Ears discharge from ears pain in ears hearing trouble full sensation in ears ringing or buzzing in ears Nose nosebleeds loss of smell stuffy, itchy or runny nose sinus problems

7 7 NOW PAST NOW PAST Mouth sore mouth or tongue loss of teeth speech difficulty loss of taste Throat persistent hoarseness loss of voice difficulty swallowing pain Neck stiffness injuries swelling tense or painful Respiratory unexplained fever night sweats chest pain when breathing shortness of breath wheezing daily cough difficulty breathing at night (wakes you up) How many pillows do you sleep on When was your last TB test? Results Have you ever been exposed to someone who had TB? Cardiovascular chest pain when walking leg vein trouble ankle swelling leg pain when walking leg pain/cramps at night heart palpitation (fluttering, skipping beats, going fast) feeling of pressure, tightness in chest, feeling of weight on chest or as though a band is squeezing chest pain in arms, jaw, under breastbone, in upper abdomen, heartburn

8 8 Have you had rheumatic fever or syphilis? When? How far can you walk or how many stairs can you climb before having to stop? What makes you stop? Do you smoke? How much? For how long? If you don t smoke now, did you ever smoke? For how long did you smoke? How much did you smoke? Do you live with a smoker? NOW PAST NOW PAST Gastrointestinal frequent or severe nausea vomiting blood/mucus in stools (circle) diarrhea constipation hemorrhoids anal itching change in bowel habits black stools indigestion heartburn vomiting blood excess belching stomach pain yellow jaundice trouble swallowing distress from fats or greasy foods stools yellow, clay-colored, have foul odor, or show undigested food (circle) bad breath, bad taste in mouth, body odor (including feet) indigestion occurs 2-3 hours after meals - fullness, bloating, sourness, etc. heavy, full or bloated feeling after eating excessive lower bowel gas history of constipation alternating with diarrhea stomach pain occurs 5-6 hours after eating, usually at night;; relieved by eating something or drinking milk above symptoms aggravated by worry or tension indigestion occurs immediately after eating

9 NOW PAST 9 nervousness, shaky feeling, headaches, relieved by eating sweets irritable if late for a meal, miss a meal or before eating breakfast sudden strong craving for sweets, alcohol or bread products wake up at night feeling hungry overweight gain weight, fail to lose weight on diets feel better mornings, worse afternoons good appetite, but fail to gain or lose weight sleepy during the day What is the most you have ever weighed? The least (as an adult)? How often do you have bowel movements? Do you strain at stool? Have you had a change of appetite? Increased / Decreased (circle one) Genitourinary frequent urgent urination painful urination night urination trouble starting urine trouble holding urine blood in urine Female Symptoms discharge from vagina sex is painful difficulty feeling sexually aroused no lubrication when aroused never or seldom have orgasms menstrual flow is excessive / decreased (circle) bleeding or spotting between periods pain before, during or after period (circle) premenstrual symptoms: cramping, water retention, breast tenderness, headaches, mood swings, irritability, depression, other cramps, nausea, back pain or other problems during period

10 NOW PAST 10 pelvic pain infertility lump(s) in breast changes in breast skin or tissue changes in nipples or discharge from nipples frequent vaginal infections Period every days. Regular? Period lasts days (average) Date of last period Number of tampons or pads used per day Have you ever had a sexually transmitted disease? What form of contraception do you use? Number of pregnancies Number of births miscarriages abortions Any complications of pregnancy? If yes, please list: How old were you when you started having menstrual periods? Male Symptoms prostate problems discharge from penis difficulty achieving or maintaining an erection painful erection difficulty with ejaculation lump(s), swelling or pain in testicles infertility What contraception do you use? Have you ever had a sexually transmitted disease?

11 11 NOW PAST NOW PAST Spine and Extremities joint pain, swelling, stiffness backaches unusual redness of palms of hands muscle cramps burning on soles of feet leg aches, growing pains Have you ever had arthritis? What joints? When? What kind? Nervous loss of balance paralysis convulsions (seizures, stiffness) lack of strength tremor (shaking, trembling) numbness Emotional / Mental feel pick-up from exercising don t remember dreams restlessness nervousness excessive worry trouble sleeping memory trouble trouble concentrating feelings of worthlessness crying spells frequent nightmares blueness or depression mood swings easily angered hard to express anger feel like killing myself fearful excess stress in life feelings of rage or violence hear voices feel others want to hurt me see things others don t trouble getting along with people always put others interests before mine loss of someone dear through don t know how to relieve stress death or separation Are you a survivor of incest or sexual, physical, or other abuse?

12 12 Lifestyle: I get up at. I go to bed at. Do you sleep well? If not, describe sleep problem: Exercise: times per week for length of time. Type(s) of Exercise: DIET DIARY: Please record below your intake of all food & drink during a 24-hour period. Please note alcohol intake per week. Breakfast: Mid-morning Snack: Lunch: Mid-afternoon Snack: Dinner: After dinner dessert/ snack/ beverage: Thank you please remember to bring nutritional/ herbal supplement bottles with you to your first visit.