NEW CLIENT HEALTH INFORMATION (REVISED 04/2014)
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- Lydia Stanley
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1 NEW CLIENT HEALTH INFORMATION (REVISED 04/2014) Sojourns practitioners work in collaboration with each other. We discuss care options at a daily meeting. We feel that we can offer the most to our patients when we continually learn from each other s experience and expertise. Information about patients is shared amongst Sojourns practitioners for treatment and follow-up purposes ONLY. Do you agree the information in your file may be shared? (Circle Yes if it is okay to share, circle No if you prefer your information not be shared. ) Yes No Signature Your name: Today s date: Your birth date: Primary Care Provider: Please list your major health concern(s): Concern(s): When did it start? If there are conditions or diagnosis not listed above, please list: Condition/Diagnosis When? Do you have allergies? Please specify: Food Drugs/Medications Environmental/Chemical Seasonal Other _ 4923 US Route 5 Westminster, VT phone (802) fax (802)
2 How do any of these issues affect your daily activities? What are your goals for your treatment at Sojourns? What might stand in the way of you achieving your goals? What gives you the most joy in life? What will you do when you are well that you are not doing now? Please list name and location (city & State) of any other health professional currently involved in your care: Name of Provider: Specialty: Treating you for: City & State Hospitalizations and Surgeries (Please include dates): 2
3 Accidents (If today s visit is because of an accident, please fill out our accident report form available at the desk): Significant Traumas: _ Birth History (prolonged labor, forceps delivery, etc): Dental History: Do you have any metal dental fillings or crowns? No Yes Not Sure Past? Present? Have you had any major dental work (root canal, bridge, implant)? Please describe: Please tell us about your family: Family Member Current Age(s) If Deceased, Age & Cause Mother Father Siblings Children Spouse or Partner Please identify your Family Medical History (circle, and write which family member): Stroke Heart Disease High Blood Pressure Depression/Anxiety Alcohol/Drug Abuse Diabetes Autoimmune Disease Seizures Thyroid Disease Mental Illness Asthma Cancer (list types): Other notes: Do you know your Blood Type? A + / - AB + / - B + / - O + / - Don t know 3
4 Please identify some of your lifestyle habits: Please tell us about your diet: Not Restricted Vegetarian Vegan Other Restrictions If restricted, please explain: Typical Daily Diet: Morning: Afternoon: Evening: How much water do you drink each day? glasses (8 oz) per day What else do you regularly drink (and how much)? Please fill in current and past use of the following substances: Substance Used in past? What? How much per day? Use Now? What? How much per day? Tobacco Yes No Yes No Recreational Drugs Yes No Yes No Alcohol Yes No Yes No Coffee/Caffeinated Tea Yes No Yes No Energy Drinks (caffeine) Yes No Soft drinks Yes No Artificial Sweeteners Yes No Yes No Are you aware of any toxic/chemical exposure in your home or workplace? Are you sensitive to fragrances or environmental chemicals? Are you sensitive to molds? Is there mold exposure at home? If Yes to any of the above, please describe: Lyme Disease Risk: (Please check all that apply) Tick infested area Frequent outdoor activities Hiking Fishing Camping Gardening Hunting Farming Ticks on pets Do you remember a tick bite? No Yes When? Do you remember a bull s eye rash? No Yes When? Other rash? No Yes When? Have you received the Lymerix vaccine? No Yes When? Have you ever been diagnosed and/or treated for Lyme disease or tick borne illness? No Yes When? 4
5 Current Weight: Ideal Weight: Highest Adult Weight: Lowest Adult Weight: Height: Do you exercise? Yes No If yes, what do you do and how often: Activity Frequency (daily? weekly?) Duration (# of minutes) Do you wear a seat belt? Yes No Do you wear a helmet when biking or skateboarding? Yes No Do you feel safe in your home? Yes No Have you ever been a victim of violence? Yes No Are you afraid that someone might hurt you? Yes No Are you afraid that you might hurt yourself or others? Yes No Please identify your current/ recent Signs and Symptoms: General Poor appetite Heavy appetite Poor sleep Heavy sleep Insomnia Fatigue Tremors Vertigo Cold hands Cold Feet Cold back Cold abdomen Fevers Chills Night sweats Sweat easily Cravings Localized weakness Poor coordination Change in appetite Sudden energy drop at (time) Peculiar taste/s Strong thirst (cold/hot drinks) Bleed or bruise easily (where?) Skin and Hair Rashes Ulcerations Hives Itching Eczema Pimples Dandruff Loss of hair Change in hair/skin texture Purpura (hives) Psoriasis Other hair or skin problems Lumps or bumps of concern Head, Eyes, Ears, Nose, and Throat Dizziness Concussions Migraines Glasses/contact lenses Eyestrain Eye pain Poor vision Night blindness Color blindness Cataracts Blurry vision Earaches Ringing in ears Poor hearing Nose bleeds Sinus Problems Mucus Dry throat Dry mouth Copious Saliva Teeth problems Jaw clicks Grinding teeth Facial pain Gum problems Spots in eyes Recurrent sore throats Dry eyes Sores on lips or tongue Headaches (where and when) Other head or neck problems 5
6 Cardiovascular High blood pressure Low blood pressure High cholesterol Irregular heartbeat Dizziness Fainting Cold hands/feet Swelling in hands/feet Blood clots Chest pain Phlebitis Difficulty breathing Other cardiovascular problems? Respiratory Cough Coughing blood Asthma Bronchitis Pneumonia Tight chest Difficulty breathing while lying down Any persistent production of phlegm? What color? Other lung problems? Gastrointestinal Nausea Vomiting Heartburn/Indigestion Diarrhea Belching Black stools Bad breath Rectal pain Hemorrhoids Gas Constipation Bloody stools Sensitive abdomen Pain or cramps Do you regularly use laxatives? How often? Do you regularly use antacids? How often? Please describe your bowel movements: color odor texture/form frequency Notes: Genitourinary Pain on urination Frequent urination Blood in urine Urgency to urinate Unable to hold urine Kidney stones Venereal disease Impotency Enlarged prostate Genital sores Do you get up to urinate overnight? How frequently? What time? Other urinary tract problems Notes: Gynecology and Pregnancy: Age at first menses Last menses (date) Frequency of periods Period duration: days Irregular periods Flow (light, medium, heavy) Clots Pain with periods Any changes in body/psyche prior to each menstruation? Do you do Breast Self Exam? Y/N Breast lumps/cyst Vaginal soreness Vaginal discharge? (describe) Last PAP (date, +/-) Birth control? Y/N Type Since when? No. of pregnancies No. of deliveries No. of miscarriages No. of abortions Menopause (approximate date of onset) Changes in body/psyche post menopause? Other thoughts? 6
7 Neuropsychological Seizures Areas of numbness/tingling Poor memory Poor balance Anxiety Concussion Depression Easily stressed Bad temper Have you ever had an eating disorder)? Please describe: Have you considered or attempted suicide? Have you ever been treated for psychological problems or substance abuse? Other neurological or psychological problems: Notes:_ Muscle/Joint/Bone Do you experience pain, weakness or numbness in your (check and circle Right and/or Left): Arms (R/L) Hands (R/L) Shoulders (R/L) Neck Back Knees(R/L) Feet (R/L) Hips (R/L) Other, please specify: Does pain affect your daily activities? If yes, please describe On a scale from 1 (least) to 10 (most), how intense is your pain currently? Do you have any other joint or bone problems? In the figure to the right, please mark areas of discomfort. 7
8 Prescription and over-the-counter medications currently taking: Name of Medication Dosage/Frequency Date Started Condition being addressed Nutritional supplements (include vitamins, homeopathic remedies, medicinal herbs): Name of Supplement Dosage/Frequency Date Started Condition being addressed 8
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