Health Questionnaire. Name: Age: Marital Status: Nationality: Occupation: Address: Telephone: (home) (work)
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1 Vitality for Life HEALTH CENTER 560 Bryne dr. Unit 1A Barrie, ON L4N 9P Health Questionnaire Name: Age: Last Name First Name Birthday: / / Sex: M F day/month/year Marital Status: Nationality: Occupation: Address: Telephone: (home) (work) Current Health Concerns: How long? What kind of treatment (if any) have you received for the problem(s)? Are you currently working with a Medical Doctor? Name: Phone: Are you currently on any medications? (include name, dose and how long you have been on it) Are you currently on any vitamins or herbal remedies?
2 Medical History: (Please provide information for each of the following ie. Dates, details) Surgeries: Date: Past Hospitalizations: Date: Accidents/Trauma: Date: Which vaccines have you received? (please include approximately when they were last given) Hepatitis B DPT HiB (influenza) Polio (injected or oral) Measles/Mumps/Rubella Tetanus Chickenpox Flu shot *Did you experience any reactions to the above vaccines? List of Medications/ Herbs taken in the past: Family History: (Please list age & health problems, or age & cause of death) Mother Father Siblings Age Health Problems Grandma(Maternal) Grandma(Paternal) Grandpa(Maternal)_ Grandpa(Paternal)_ Please list the 3 most significant stressful events in your life, from the most recent to the most distant. Are any of these situations still impacting your life? Y N 1. date 2. date 3. date
3 Present Health Situation: Current weight Weight 1 year ago As an adult, what has been your maximum & minimum weight Please rate the following by putting a line at your current situation (0=lowest/poor, 10=highest/excellent): Overall Health Energy Sleep Level of Pain (if any) 10 is most painful Eating Habits Feeling of control over your life Feeling of control over your health Body image (are you content with how your body looks) Job satisfaction Supportive/Relaxing Home environment Stress Level
4 Review of Systems: Indicate whether you experience, or have ever experienced any of the following Please circle one of the following: Y=yes, N=no, P=in the past Skin Rashes Itching Eczema/hives Psoriasis Acne/boils Color changes Lumps Night sweats Dryness/moistness Temperature Nail changes Change in mole Skin cancer Excessive sun exposure Photosensitivity Head, Nose & Sinuses Headaches Head Injury Dizziness Nasal discharge Frequent Colds Nose bleeds Sinus infections Hay fever Cavities Frequent sore throat Tonsillitis Sore mouth/tongue/gums Hoarseness Loss of taste Eyes Blurred vision Eye pain Do you wear glasses? Tearing/dryness Double vision Glaucoma Cataracts Bothered by sun Itching Redness Discharge Blind spot Ears Impaired hearing Earache Dishcharge Infections Dizziness Neck Lumps Swollen glands Goiter Pain/stiffness
5 Respiratory Cough Sputum/Mucus Spitting up blood Wheezing Asthma Bronchitis Pneumonia Do you get sick often? Emphysema Difficult breathing Pain on breathing Shortness of breath Tuberculin test Shortness of breath lying down Date of last chest X-ray Tuberculosis Do you smoke? How much? Cardiovascular Heart disease Angina High blood pressure Murmurs Rheumatic fever Chest pain Swelling in ankles Palpitation/fluttering Cyanosis (blue skin) Heart monitor Have you had an ECG Gastrointestinal Ulcer Trouble swallowing Change in thirst Change in appetite Nausea Vomiting Vomiting blood Belching/passing gas Indigestion Jaundice (yellow skin) How many bowel movements per day? Food allergy Liver disease Gallbladder disease Heartburn Diarrhea Rectal bleeding Hemorrhoids Black stool Abdominal pain Constipation Urinary Pain on urination Inability to hold urine Increased frequeny Frequency at night Frequent infections Kidney stones Blood in urine Urgency Hesitancy Breasts Lumps Pain/tenderness Nipple discharge Fibrocystic breasts Do you do self exams? Have you breast fed? Date of last mammogram Date of last in-office exam Breast augmentation surgery?
6 Female Reproductive Age menses began # of days of flow (menses) Length of cycle (ie. 28days) Bleeding between periods Are cycles regular Painful periods Excessive flow PMS Endometriosis Pain on intercourse Birth control used? Number of live births # of pregnancies # of abortions # of miscarriages Sexual difficulty Difficulty conceiving Are you sexually active Venereal disease Vaginal discharge Vaginal itching Excessive dryness Date of last menses Date of last PAP Male Reproductive Discharge/sores Hernia Testicular pain Sexual difficulty Venereal disease Are you sexually active Muskuloskeletal Arthritis Joint pain/stiffness Broken bones Weakness Muscle spasms/cramps Joint swelling Backache Peripheral Vascular Varicose veins Deep leg pain Cold hands/feet Thrombophlebitis Leg cramps Extremity numbness Extremity coldness Extremity swelling Extremity ulcers Neurologic Fainting Seizures/convulsions Paralysis Muscle weakness Numbness/tingling Loss of memory Loss of balance Involuntary movement Speech problems Endocrine Thyroid trouble Heat/cold intolerance Excessive thirst Excessive hunger Excessive urination Excessive sweating Diabetes Hypoglycemia Hormone therapy
7 Blood / Lymphatic Anemia Easy bleeding Easy bruising Past transfusions Lymph node swelling Allergic History Drug sensitivity Reaction to vaccine History of anaphylaxis List Allergies: Mental / Emotional Depression Mood swings Anxiety / nervousness Insomnia Psychiatric disorder: Habits / Hobbies How many meals do you eat in a day Do you snack throughout the day? Do you watch television? Do you work on a computer daily? How many hours? How many hours? Do you consume alcohol? Do you use recreational drugs? How much? /week How often? How old is your home? Is it carpeted? Y N Do you have Pets? Y N What is your water source? (filtered, well, distilled, tap, bottled) How much water do you drink every day? Are you exposed to second-hand smoke? Y N What do you enjoy most in your life Do you take vacations? How often What do you do for exercise? How often What are your interests/hobbies What do you worry most about in life What is the biggest factor stopping you from achieving your ultimate health goals? Is there anything else that you feel is important to help me understand your current health situation?- Did you know that Vitality For Life offers the following service? Please check if you would like more information in the following areas: Chiropractic Massage Therapy Hot Stone Massage Orthotics Acupuncture Aromatherapy Massage
8 Vitality for Life HEALTH CENTER 560 Bryne dr. Unit 1A Barrie, ON L4N 9P Day Diet Diary Please keep track of all foods that are eaten (don t worry about quantities) for 4 days, and note the time that you ate them. Include all beverages and snacks consumed during this time as well, and comment on how you felt throughout the day (energy level, indigestion, bloating/gas). Day: Morning: Afternoon: Evening: Comments:
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Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
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