ADULT HISTORY CURRENT STATUS 1.! 3. 2.! 4.
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1 If you have any recent Radiologic Studies or Blood Work please bring it with you. ADULT HISTORY Name:!!! Date: D.O.B:!!! Age:!!!! M F CURRENT STATUS PRIMARY PROBLEMS: 1.! 3. 2.! 4. SYMPTOM DRAWING Please mark the areas on the diagrams below where you feel these symptom ms, using the codes indicated. Include all the affected areas. ACHE SHARP NUMB BURNING PRESSURE TIGHT/STIFF TINGLING ~~~~~~ >>>>>>> XXXXX //////// ****** Page1
2 When did the problem(s) begin? What caused the problem(s)? MVA Work Injury Computer use Fall Bend Twist Lift Push/ Pull Sports Injury Other trauma Unknown Other If there was an injury, please describe: What makes the problem better or worse? (i.e.- activities, medications, therapies, time of day, etc) Are you getting: Better Worse No change Unsure Have you had or are you getting treatment for your problem? (Include treatment from physicians, chiropractors, massage therapists, physician therapists, acupuncturists or any other healthcare provider) Yes No! If ʻYes,ʼ please enter: Healthcare provider Specialty Diagnosis Therapy received Result Page2
3 Have you had any of the diagnostic tests for your problem(s)? Yes No! If ʻyes,ʼ please indicate below: Dates Body Area!! Results X-Ray:! CAT Scan:! MRI:!!! Bone Scan:!! EMG:!!! Bone Density:! EEG:!!! Labs:!! Other:!! Trauma History: (Please give details and approximate dates) None: 1. Head trauma / Concussion: 2. Motor vehicle accidents: 3. Injuries (sports, falls, etc.): 4. Physically demanding activities (sport, arts, crafts,etc.) 5. Dental work (extractions, braces, etc.): 6. Injuries from giving birth: 7. Emotional trauma: 8. Other: Do you have any of the following? (check those that apply) Arthritis Torn Ligaments Tendonitis Carpal Tunnel Syndrome Disc Disease Lyme Disease Fibromyalgia Cancer Chronic Fatigue Syndrome ADD/ADHD Depression/Anxiety Thyroid Disease Trigeminal Neuralgia Bellʼs Palsy HIV / AIDS Diabetes Mellitus High Cholesterol/Triglycerides Other Important Illness? Page3
4 Female Reproductive History:!!! NONE: Pregnancies: Number Term Premature Abortions/Miscarriages Living!! Prenatal problems:! Delivery type:! Procedure /Complication:! Postpartum problems:! Surgical History: (check all that apply)!! NONE: Disc/Laminectomy Fracture repair Ligament repair Torn cartilage Spinal fusion Joint repair / replacement C-section Gallbladder Appendix Prostate Breast Sinus Ear Nose Tonsils/adenoids Dental Angioplasty Bypass Laparoscopic procedures Cosmetic Other (please elaborate) Medications: NONE: Please list all medications including dose and number of times taken per day. Include prescriptions, vitamins, supplements, remedies, etc. Allergies / Sensitivities: Are you allergic to any medications? Yes No Please list any reactions you have to medications, foods, the environment or chemicals Page4
5 Social History Work Environment: Job title/duties: Responsibilities/Satisfaction Physical Demands/Ergonomics: Habits:! Amount! Frequency # of Years When Quit! Never Smoking: Alcohol: Drugs: Sweeteners: Health Maintenance: Physical Activity (type/frequency): Hobbies / Recreation (type/frequency): Diet (protein / carbs / veggies / fruits / snacks / sugar): Fluid intake (type, amount/day): Sleep / Rest (hours/day, quality): Family History! Age!! Health Status!!! Death (cause/age) Father:!! Mother:!! Siblings:!!!! Children:!!!! If you have any relatives with problems similar to your primary problem, please identify them and the problem: None Page5
6 Other Information Is there anything else you would like to share? NONE: REVIEW OF SYSTEMS (*Please Check and Circle ALL that apply*)!!!!! NONE: General! Nervous System ( ) Weight gain or loss, change in appetite/ thirst! ( ) Seizures, tremors ( ) Fatigue, weakness, change in sleep pattern! ( ) Headache, head injury ( ) Fever, chills, night sweats, cold intolerance! ( ) Numbness, tingling ( ) High Cholesterol +/0 Triglycerides! ( ) Loss of coordination! ( ) Dizziness/ Vertigo Head, eyes, ears, nose and throat! ( ) Poor memory or concentration ( ) Eye pain/ disease, visual problems! ( ) Stroke, TIA, fainting ( ) Chronic sinusitis, nasal discharge! ( ) Change in taste, smell ( ) Sore throat, change in voice! ( ) Neurologic disease, i.e., MS ( ) Difficulty swallowing!!! Musculoskeletal system Skin! ( ) Joint pain, redness, swelling, stiffness ( ) Itching, burning, rashes (psoriasis, eczema, etc)! ( ) Frequent/ severe muscle pain/ weakness ( ) Lumps, tumors, cancer! ( ) Disc herniation ( ) Changes in moles/ warts/ lesions! ( ) Short leg syndrome! ( ) Abdominal curvature of the spine Cardiovascular! ( ) Workers comp injuries ( ) Chest pain, heart attack, angina ( ) Palpitations, arrhythmia, heart murmurs! Psychological ( ) Blood vessel disease, clots, thrombophlebitis! ( ) Often nervous/ worried ( ) Foot/ Ankle swelling, heart failure! ( ) Post traumatic stress disorder ( ) High blood pressure! ( ) Constant feelings of sadness or hopelessness! ( ) Hospitalized for mental illness Respiratory! ( ) Psychological diagnosis ( ) Wheeze, asthma, use of inhalers ( ) Shortness of breath with activity/ at rest! Female Endocrine/ Reproductive ( ) Frequent cough, bronchitis, COPD! ( ) Decreased sense of well-being, decreased ( ) Pneumonia, flu, RSV! energy! ( ) Decreased mental sharpness/ indecisiveness Gastrointestinal! ( ) Sexual dysfunction: decreased desire, pain ( ) Nausea/ Vomiting, abdominal pain, ulcer! ( ) Menstrual irregularity: flow, bloating, PMS ( ) Heartburn, reflux, hiatal hernia! ( ) Endometriosis, fibroids ( ) Change in bowel habits: freq., color, consistency! ( ) Infertility, miscarriages ( ) Irritable bowel synd., excessive gas, food intol.! ( ) Menopausal, Peri-Menopausal ( ) Inflammatory Bowel Disease: Crohnʼs / Ulc. Colitis! ( ) Breast lumps/ cysts/ tumors, nipple discharge ( ) Liver/ Gallbladder disease! ( ) Osteopenia/ osteoporosis Page6
7 UrinaryMale Endocrine/ Reproductive ( ) Sexually transmitted diseases ( ) Frequent UTI, pain w/ urinating ( ) Incontinence or difficulty urinating ( ) Kidney Stones, tumors, procedures ( ) Decreased sense of well-being, decreased energy ( ) Decreased mental sharpness/ indecisiveness ( ) Erectile Dysfunction ( ) Sexual dysfunction: desire, pain infertility ( ) Loss of muscle mass, strength ( ) Prostate disease Other problems (not listed above): None: History Reviewed (Date and Initial): Osteopathic Principles and Practice Discussed: Daniel Lopez, D.O. Date: Page7
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Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
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WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM
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REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
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CHIROPRACTIC INTAKE FORM
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Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)
Date: Patient Name: D.O.B Last First M.I History of Present Illness: What is the reason for your visit? Date symptom started? Please list any treatments you have previously had for current illness. (Physical
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Mayflower Acupuncture LLC
536 Hopmeadow St. Simsbury, CT 06070 Phone: (860) 413-2118 Email: Forms@mayfloweracupuncture.com Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this
* CC* PATIENT QUESTIONNAIRE
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MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014 Name: Date of Birth: Today s Date: Where did you get healthcare before? May we request records? Y N (requires signed release)