Rian Shah, ND Mark Woodall, ND

Transcription

1 NEW PATIENT MEDICAL QUESTIONNAIRE Please complete the following medical questionnaire to the best of your ability. You may need family members to help supply information. You will notice that this is a longer questionnaire than you typically complete at the doctor s office. The breadth and depth of this medical history intake form are essential to identify the various interacting factors that may contribute to your physical and/or psychological symptoms. Your answers will help guide which laboratory tests may be the most appropriate for you. The thoroughness of your answers to these questions will not only help us determine the root cause of your health concerns but also help us define an effective treatment program. It will also enable us to make the most economical use of our consultation time: you won t be paying us to ask these questions and record your answers during the visit. We are interested in what might be considered minor complaints, as well as major problems. Some patients are reluctant to mention multiple symptoms for fear that they will be viewed as hypochondriacal. The philosophy of our practice is different. We listen to all the messages your body communicates, no matter how seemingly irrelevant, odd, idiosyncratic, or inexplicable. Such symptoms can often be valuable clues in the kind of medical detective work we will do together. So, please include as much information as you can on this form. Please print or write legibly. PATIENT NAME CHIEF COMPLAINTS/CONCERNS Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptoms has been present

2 What diagnosis or explanations have been given to you? When was the last time you felt really well for more than a few days at a time? What life events happened around the same time that you started feeling bad? Trips out of the country? Anything you can correlate with your symptoms? What makes you feel worse? What makes you feel better? Please list all physicians or other health care providers you have seen for your listed health conditions To what extent have prior treatments been helpful? Allergies to medications: Allergies to food or environment: 2

3 Current medications and doses: Current supplements and doses: PAST MEDICAL & SURGICAL HISTORY ILLNESSES Please indicate the illnesses you have had in the past along with the approximate date. Chicken pox Measles Mononucleosis Mumps Whooping cough Tonsillitis Anemia Arthritis Asthma Bronchitis Cancer Chronic fatigue syndrome Chronic constipation Crohn s disease or ulcerative colitis Diabetes Emphysema Other (describe) 3 Epilepsy Gallstones Gout Heart attack or angina Heart failure Hepatitis High blood pressure Irritable bowel Kidney stones Pneumonia Rheumatic fever Sinusitis Sleep apnea Stroke Thyroid disease

4 INJURIES Head injury Back injury Neck injury Fracture Other (describe) DIAGNOSTIC STUDIES Please indicate DATES next to each. Chest X-ray Mammogram EKG Sigmoidoscopy Colonoscopy Upper GI series CAT scan X-ray MRI Bone density test Carotid artery ultrasound Blood tests Barium enema Other (describe) OPERATIONS Please list operations and dates

5 CHILDHOOD ILLNESSES AND CONDITIONS Please indicate which, if any, of the following conditions developed when you were a child (before age 12) by indicating the approximate age of onset. Frequent colds or flu Bronchitis Measles Chicken pox Tonsillitis Chronic constipation Mumps Whooping cough Seasonal allergies Behavior problems Hyperactivity Frequent headaches Upset stomach, indigestion Congenital abnormalities Pneumonia Parent(s) smoked Skin disorders (eczema) Encopresis (fecal incontinence) Strep infections Significant dental work ADD Difficulty learning Ear infections Premature at birth Fever blisters Abusive or alcoholic parent(s) Bed wetting Colic Major illness(s) that required hospitalization. If yes, please explain your illness: FEMALE MEDICAL HISTORY OBSTETRICS HISTORY Please indicate how many where appropriate. Pregnancies Caesarean section Vaginal deliveries 5

6 Miscarriage Abortion Living Children Postpartum depression Toxemia Gestational diabetes Breast feeding For how long? GYNECOLOGICAL HISTORY Hysterectomy (complete or partial): Yes No Age at 1st period: Menses frequency: Length: Pain: Yes No Clotting: Yes No Has your period skipped? For how long? Last menstrual period: Do you currently use contraception? Yes No If yes, what type do you use? Condom Diaphragm IUD Partner vasectomy Have you ever used hormonal contraception? Yes No If yes, when Birth control pills/how long? Patch/How long? Nuva ring/how long? Are you using the pill now? Yes No Does/did taking the pill produce side effects? Yes No What are/were they? In the 2nd half of your cycle, do you experience any of the following? Yes No 6

7 Breast tenderness Water retention Irritability or PMS Date of last mammogram Date of last PAP test: Normal Abnormal Date of last bone density test: Results: High / Low / Normal Are you in menopause? Yes No Age at menopause Do you take: estrogen, progesterone or testosterone? If so, type and application method (oral, injection, transdermal, patch) How long have you been on hormone replacement? FAMILY HISTORY Please mark any health problem(s) your family has suffered with, either now or in the past. Stroke Uterine cancer Colon cancer Breast cancer Ovarian cancer Prostate cancer Diabetes (type 1 or 2) Obesity Depression Alcohol or Drug Addiction High Blood Pressure High Cholesterol Osteoporosis Heart Disease Other 7

8 SOCIAL/LIFESTYLE HISTORY TOBACCO HISTORY Currently using tobacco? Yes No How many years? Packs per day: Are you exposed to 2nd hand smoke? Yes No If yes, please explain: ALCOHOL INTAKE How many drinks currently per week? For example: 1 drink = 5 ounces wine or 12 oz. beer or 1.5 ounces spirits. None >10 Past alcohol intake? Yes/No How many drinks per week? >10 Have you ever been told to cut down your alcohol intake? Yes No Do you get annoyed when people ask you about your drinking? Yes No Do you ever feel guilty about your alcohol consumption? Yes No Do you ever drink in the morning? Yes No Do you notice a tolerance to alcohol (can you hold more than others?) Yes No 8

9 Have you ever been unable to remember what you did during a drinking episode? Yes No Do you get into arguments or physical fights when you have been drinking? Yes No Have you ever been arrested or hospitalized because of drinking? Yes No Have you ever thought about getting help to control or stop your drinking? Yes No REVIEW OF SYSTEMS Write 1 if mild, 2 if moderate, and 3 if severe. If it is a problem you had in the past (but not currently), write P (with no numbers). If necessary, add explanatory comments next to these items. GENERAL Frequent fevers Chills/cold all over Aches/pains General weakness Difficulty sweating Excessive sweating Swollen glands Cold hands & feet SKIN Sore when touched Cuts heal slowly Bruise easily Rash Pigmentation Fatigue Difficulty falling asleep Sleep walking Nightmares No dream recall Early waking Daytime sleepiness Distorted vision Changing moles Calluses Eczema Psoriasis Dryness 9

10 Oiliness Itching Acne Hives Fungus on nails Oily skin Peeling skin Cracking skin Skin is sensitive to: Sun Fabrics Shingles Nails split White spots/lines on nails Crawling sensation Burning on bottom of feet Athletes foot Skin cancer Strong, unpleasant body odor Detergents HEAD Inability to concentrate Confusion Headaches Concussion or whiplash Mental sluggishness Forgetfulness Indecisiveness Face twitch Poor memory Hair loss EYES Sand in eyes Double vision Blurred vision Poor night vision Bright flashes Halo around lights Eye pain Dark circles under eyes Strong light irritates Cataracts Floaters Visual hallucinations 10

11 EARS Aches Discharge or conjunctivitis Pain Ringing Deafness or hearing loss Itching Pressure Need to wear a hearing aid Frequent infections Tubes in ears Sensitive to loud noises Auditory hallucinations NOSE AND SINUSES Stuffy Bleeding Discharge Seasonal allergies. If yes, they are worse in the: Spring Summer Infection Polyps Fall Winter MOUTH Coated tongue Sore tongue Teeth problems Cavities Amalgam fillings Bleeding gums Canker sores TMJ Cracked lips or corner of mouth Chapped lips Fever blisters Wear dentures Grind teeth when sleeping Bad breath Bad taste in mouth Dry mouth 11

12 THROAT Mucus Difficulty swallowing Frequent hoarseness Tonsillitis NECK Stiffness Swelling CIRCULATION AND RESPIRATION Swollen ankles Sensitive to heat Sensitive to cold Extremities cold or clammy Hands or feet go to sleep (numbness) High blood pressure Chest pain Pain between shoulders Dizziness upon standing Fainting spells High cholesterol High triglycerides Wheezing Irregular heartbeat Palpitations Low exercise tolerance Frequent coughs Breathe heavily Enlarged glands Frequent clearing of throat Throat closes up Lumps Neck glands swell Frequently sighing Shortness of breath Night sweats Varicose veins Mitral valve prolapse Heart murmurs Skipped heartbeat Heart enlargement Angina pain Bronchitis or pneumonia Emphysema Croup Frequent colds Heavy or tight chest Past heart attack? When Phlebitis Spider veins 12

13 GASTROINTESTINAL AND DIGESTION Peptic or duodenal ulcer Poor appetite Excessive appetite Gallstones Gallbladder pain Nervous stomach Uncomfortably full feeling after meal Indigestion Heartburn Acid reflux Hiatal hernia Nausea Vomiting Vomiting blood Abdominal pains or cramps Gas Diarrhea Constipation Changes in bowel movements Rectal bleeding Tarry (black) stools Rectal itching Use laxatives Bloating Belch frequently Anal fissures Bloody stools Undigested food in stools Hemorrhoids KIDNEY AND URINARY TRACT Kidney pain Kidney stones Kidney infections Bladder infections Problem passing urine Painful urination Frequent urination Blood in urine Burning urination Nocturia (frequent urination at night). If yes, how many times must you get up/night 13

14 WOMEN S SYMPTOMS OR CONDITIONS Fibrocystic breasts Lumps in breast Fibroid tumors in breast Spotting Heavy periods Fibroid tumors in uterus Painful periods Change in period Breast soreness before period Endometriosis Non-period bleeding Breast soreness during period Vaginal dryness Vaginal discharge Partial or total hysterectomy Hot flashes Mood swings tied to menstrual cycle Concentration or memory problems Breast cancer Ovarian cysts Pregnant Infertility Decreased libido Miscarriage Heavy bleeding Joint pain Headaches Weight gain Loss of control of urine Palpitations MEN S SYMPTOMS OR CONDITIONS Prostate enlargement Prostate infection Change in libido Diminished libido Impotence Infertility Lumps in testicles Sore on penis Genital pain Hernia Prostate cancer Low sperm count Difficulty obtaining erection Difficulty maintaining an erection Urgency/hesitancy/change in urination Loss of control of urine 14

15 Have you had your PSA measured? Yes No If yes, indicate the PSA level: >10 CONDITIONS SPECIFIC TO CHILDHOOD OR CHILD PATIENTS Conduct issues Discipline problems Aggressive behavior Hyperactivity Temper tantrums Depression Anxiety Poor impulse control Panic attacks Phobias Poor self-esteem Identity concerns Witness to violence Bedwetting or soiling Appetite disturbance Eating issues Sleep disturbance Learning problems Lack of motivation Speech problems Family communication problems Death or major illness in family Adjusting to divorce or separation Parental stress Single parenting problems Step-parenting problems ANTIBIOTIC USE Antibiotics: How often have you taken antibiotics? STEROID USE How often have you taken oral steroids (e.g. prednisone, cortisone, etc.)? 15

16 NUTRITION AND LIFESTYLE HISTORY Have you made any changes to your eating habits because of your health? Yes No Do you currently follow a special diet or nutritional program? Yes No If yes, please indicate all that apply: Low fat Mixed food diet (animal and vegetable sources) High protein Gluten restricted Low sodium Fat restricted Low starch or carbohydrate The blood type diet The Zone diet Total calorie restriction Ovo-lacto diet Diabetic No dairy Wheat free or gluten-free Vegetarian Vegan Metabolic Typing diet Specific program for weight loss or weight maintenance. If yes, what type What food restrictions do you have? Do you read food labels? Yes No How many meals do you eat out per week? >5 16

17 Indicate which of the below affect your lifestyle and eating habits: Significant other or family members have special dietary needs of food preferences Love to eat Eat because I have to Have a negative relationship with food Struggle with eating issues Emotional eater (eat when sad, lonely, depressed, bored, anxious, etc.) Eat too much under stress Eat too little under stress Don t care to cook Eating in the middle of the night Confused about nutritional advice Diet often for weight control Fast eater Erratic eating habits Eat too much Late night eater Dislike healthy food Time constraints Eat more than 50% of meals away from home Travel frequently Healthy foods unavailable Do not plan meals or menus Rely on convenience items Poor snack choices Significant other or family members don t like healthy foods 17

18 How much of each water type do you consume each day (8 oz. glasses/day)? Tap Distilled Spring Well Reverse osmosis Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? Yes No If yes, please explain If yes, what food and symptom(s) (for example, wheat gas and bloating)? Do you experience delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes No If yes, what food and symptom(s) Which of the following do you eat/drink/consume weekly, and how often? Candy Cheese Chocolate Cups of caffeinated coffee or tea Cups of caffeinated tea Cups of decaffeinated coffee or tea Cups of hot chocolate Diet sodas (12 oz. can or bottle) Caffeinated soda (12 oz) Decaffeinated soda (12 oz) Energy drinks (12 oz) Ice cream Salty foods Slices of white bread (rolls/bagels) 18

19 Do you feel worse when you eat a lot of: High fat foods High protein foods High carbohydrate foods (breads, pasta, potatoes) Do you feel better when you eat a lot of: High fat foods High protein foods High carbohydrate foods (breads, pasta, potatoes) Refined sugar (junk food) Fried foods 1 or 2 alcoholic drinks Other (please explain) EXERCISE Current exercise program: Exercise type # of sessions/wk Duration of Activity 19

20 List problems that limit activity Do you feel unusually fatigued after exercise? Yes No If yes, please describe Do you usually sweat when exercising? Yes No Please include here any additional information about you or your health that you think are important for me to know 20