Patient Health History. Name: Date: First Middle Last. Street Address: City: State: Zip Code:
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- Asher Ramsey
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1 STEPHEN D. SAEKS, PhD, LAc 2 Roads Crossing Healthcare, PC NW Greenbrier Parkway, Suite 240 Beaverton, Oregon Patient Health History Name: Date: First Middle Last Street Address: City: State: Zip Code: How did you hear about my practice? Friend Family Member Web Site (if so, please list site) Other Successful healthcare and preventative medicine are only possible when I have a complete understanding of your physical, mental, emotional, and social situation. Please complete this questionnaire as thoroughly as possible to help me develop such an understanding. Please print or write legibly and mark any areas of confusion with a question mark (?). Thank you. 1. Are you currently receiving healthcare? N Y If yes, where and from whom If no, when was the last time you did? What was the reason? 2. Has your case been referred to an attorney or are you planning to refer it to an attorney? N Y 3. Please identify the health concerns that have brought you to my clinic: Condition Past Treatment a. b. c. d. Page 1 of 6
2 4. What are the most important health problems/concerns? Please list in order of importance. a. c. b. d. 5. Do you have any reason to believe that you are pregnant? N Y If you are pregnant, approximately how far along is your pregnancy? 6. Do you have any chronic infections or infectious diseases? N Y If yes, please explain: 7. Are you currently suffering from any chronic illnesses? N Y 8. If applicable, please list any foods, drugs, or medications to which you are hypersensitive or allergic (please include the type of reaction): 9. Please circle any of the following medications that you are currently taking: Laxatives Pain Relievers Antacids Thyroid Medication Appetite Suppressants Antibiotics Antidepressants Tranquilizers/Sleeping Pills Blood pressure Medication Other 10. Please list the name(s) of any of the above medications that you are currently taking: 11. Height: Current Weight: Past Max. Weight/When: Past Min. Weight/When: 12. What is your most recent Blood Pressure reading? / When was this reading taken? 13. Please circle any childhood illnesses that you had: Scarlet Fever Diptheria Mumps Rubella Measles German Measles Chicken Pox Other: 14. Please circle any immunizations you have had: Polio Tetanus Measles/Mumps/Rubella Pertussis Diptheria Other: 15. Please list any surgeries or hospitalizations: a. Reason: When: b. Reason: When: c. Reason: When: Page 2 of 6
3 d. Reason: When: 16. Please list any X Rays/CAT Scans/MRI's/NMRI's/Special Studies a. Reason: When: b. Reason: When: c. Reason: When: d. Reason: When: 17. Family History: Mother Father Brothers Sisters Spouse Children Age (if living) Health (Exc, Good, Poor) Age at death (if deceased) Cause of Death Check below, any conditions that members of your family have or have had... Diabetes Cancer Heart Disease High Blood Pressure Stroke Mental/Emotional Other (please list) 18. Please circle any of the following that you experience now and underline any you have Anxiety Depression Mood Swings Suicidal Thoughts/Feelings Excessive Fears (phobias) Periods of Extreme Activity or Elevated Mood Unusual Thoughts or Feelings 19. Please circle any of the following that you experience now and underline any you have Fatigue Slow Wound Healing Frequent/Chronic Infections Chronic Fatigue Syndrome 20. (Head, Eye, Ear, Nose, and Throat) Please circle any of the following that you experience now and underline any you have Impaired Vision Eye Pain/Strain Glaucoma Glasses/Contacts Tearing/Dryness Page 3 of 6
4 Impaired Hearing Ear Ringing Earaches Headaches Sinus Problems Nose Bleeds Frequent Sore Throats Hay Fever Teeth Grinding Teeth Grinding/Jaw Problems 21. (Respiratory) Please circle any of the following that you experience now and underline any you have experienced in the past: Pneumonia Frequent Common Colds Difficulty Breathing Emphysema Persistent Cough Pleurisy Asthma Tuberculosis Shortness of Breath Other Respiratory Problems/Issues: 22. (Cardiovascular) Please circle any of the following that you experience now and underline any you have experienced in the past: Heart Disease Chest Pain Swelling of Ankles High Blood Pressure Low Blood Pressure Varicose Veins Palpitations/Fluttering Stroke Heart Murmur Rheumatic Fever 23. (GI) Please circle any of the following that you experience now and underline any you have Ulcers Changes in Appetite Nausea/Vomiting Epigastric Pain Passing Gas Heartburn Belching Gall Bladder Disease/Stones Liver Disease Hepatitis B or C Hemorrhoids Abdominal Pain Diarrhea Constipation Undigested food in Stool Mucous in Stool Blood in Stool a. Do you have cravings for any particular foods or flavors? N Y If yes, please list: 24. (GU) Please circle any of the following that you experience now and underline any you have Kidney Disease Painful Urination Frequent Urinary Tract Infections Frequent Urination Kidney Stones Impaired Urination Frequent Urination at Night Difficulty Starting Difficulty Stopping Dribbling Weak Stream Blood in Urine 25. (Female Reproductive) Please circle any of the following that you experience now and underline any you have Breast Lumps/Tenderness Nipple Discharge Irregular Cycles Heavy Flow Clotting PMS/PMDD Bleeding Between Cycles Difficulty Conceiving Vaginal Discharge Menopausal/Perimenopausal Symptoms 26. Menstrual/Birthing History 1. Age at first menses: 2. # of days of menses/flow 3. Length of cycle: 4. Birth Control Y N (method): 5. # of pregnancies: 6. # of Miscarriages: Page 4 of 6
5 7. # of Abortions: 8. # of Live Births: 9. # of Vaginal Deliveries: 10. # of C Sections: 27. (Male Reproductive) Please circle any of the following that you experience now and underline any you have Prostate Problems Testicular Pain/Swelling Penile Discharge Erectile Difficulties Premature Ejaculation Delayed Ejaculation Other: 28. (Musculoskeletal) Please circle any of the following that you experience now and underline any you have Neck/Shoulder Pain Leg Pain Arm Pain Low Back Pain Upper Back Pain Mid Back Pain Muscle Spasms/Cramps (if so, where): Joint Pain (if so, where): 29. (Neuro) Please circle any of the following that you experience now and underline any you have Vertigo/Dizziness Paralysis Numbness/Tingling Loss of Balance Seizures/Epilepsy 30. (Endocrine) Please circle any of the following that you experience now and underline any you have Hypothyroid Hyperthyroid Hypoglycemia Diabetes Mellitus Night Sweats Feeling Hot or Cold 31. (Skin) Please circle any of the following that you experience now and underline any you have Dry Eczema Psoriasis Seborrhea Frequent Rashes Acne Bruises Other: 32. (Lifestyle) a. Please indicate your typical food intake Breakfast: Lunch: Dinner: Snacks: b. Daily Exercise: c. Sleep Habits: d. Education: e. Occupation: Nature of Work: Hrs./wk: Do you enjoy work N Y Why/why not: f. Nicotine/Caffeine/Alcohol Use N Y Amount of each and frequency: Page 5 of 6
6 g. Consumption of water/day: Preferred Temperature: Cold Cool Room Temp Warm Hot h. Have you experienced any major traumas? N Y If yes, please explain to the extent that you are comfortable: i. How do you spend your leisure time? Is there anything else you think it would be helpful for me to know or that you would like to tell me? Thank you very much for taking the time to openly complete this form Page 6 of 6
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