Personal Health Evaluation
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- Shanna Horton
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1 Personal Health Evaluation Note: Information provided on this forms will be held in strict confidence. I. Personal Information Name Age Sex Height Weight Eye Color Phone Number or Skype Number you wish to be contacted at II. Diet, Nutrition and General Health Practices a. On average, how many servings do you have per day of the following. Food (serving size) Servings Food (serving size) Servings Fresh Fruits (1/2 cup servings) White Bread (1 slice) Fresh Vegetables (1/2 cup servings) Refined Sugar (1 teaspoon) Green Leafy Vegetables (1/2 cup servings) Cookies, cakes, pastries Fresh or Frozen Fish (3-4 ounces) Alcohol (1 oz.) Poultry (Chicken or Turkey) (3-4 oz.) Coffee (1 cup) Red Meat (3-4 oz.) Soda Pop (8 oz.) Seafood (Shrimp, Crab, etc.) (3-4 oz.) Artificial Sweeteners Milk (1 cup) Soymilk or other milk substitute (1 cup) Butter (1 oz.) Margarine (1 oz.) b. How much water do you drink each day? cups. What kind of water do you drink? a. How much sleep do you get each night on the average? hours. How do you sleep? b. How often do you exercise? hours per. What do you do for exercise? c. What is your energy level like? d. How often do your bowels eliminate? e. Are you pregnant or nursing a baby? Personal Health Evaluation, Page 1
2 e. Do you feel like you are under stress? If so, explain. f. What nutritional supplements are you currently taking (attach separate sheet if necessary)? g. What are current health concerns are you seeking help for (attach separate sheet if necessary)? h. What medications, medical procedures, supplements or therapies have you previously tried for your condition (attach separate sheet if necessary)? Were any of these supplements or therapies helpful? If so, please note which ones were helpful. Personal Health Evaluation, Page 2
3 III. Medical Information a. Are you under a medical doctor s care for your condition? If so, what are you being treated for? b. Are you currently taking any prescription or over-the-counter drugs? If so, please list each drug and what it is for. c. Have you been diagnosed by a licensed physician with any of the following? Check all that apply. AIDS Angina Arthritis (Rheumatoid) Arthritis (Osteo) Arrhythmia (irregular heart beat) Asthma Attention Deficiet Disorder (ADD/ADHD) Autoimmune Disorders, Specify: AIDS Angina Arthritis (Rheumatoid) Arthritis (Osteo) Arrhythmia (irregular heart beat) Asthma Attention Deficiet Disorder (ADD/ADHD) Autoimmune Disorders, Specify: Benign Prostatic Hyperplasia (BPH) Bipolar Mood Disorder (Manic Depressive Disorder) Bleeding Disorders Cancer, Specify type: Cardiac Arrest (Heart Attack) Celiac Disease Chronic Obstructive Pulmonary Disorder (COPD) Cirrhosis of the Liver Colitis Congestive Heart Failure Depression Diabetes Eczema Endometriosis Epilepsy Fatty Liver Disease Fibromyalgia Graves Disease (Hyperthyroid) Hahsimoto s Disease (Thyroiditis) Hepatitis High Blood Pressure (Hypertension) Irritable Bowel Disorder (Crohn s or Colitis) Kidney Stones Low Thyroid (Hypothyroid) Lupus Multiple Sclerosis Obsessive-Compulsive Disorder Osteoporosis Psoriasis Ulcers Other, specify: Personal Health Evaluation, Page 3
4 IV. Specific Symptoms a. Check any of the following emotions you find it difficult to deal with, either in yourself or others. Emotion Problem with Self Problem with Others Explain Anger Irritability Frustration Anxiety Fear Sadness Depression Excitement Laughter Lack of enthusiasm Lack of joy Worry b. Digestive, Liver and Intestinal Symptoms. Check all that apply. Abdominal pain or discomfort Acid indigestion, heartburn or acid reflux Bad breath Bloating, belching or intestinal gas Constipation (bowel movements less than once per day) Cravings for sugary foods Diarrhea or loose stools: Food allergies, specify foods that give you problems: Food sits heavy on stomach after meals Groggy feelings in the morning Hard, dry stools Hemorrhoids or anal fistula Loss of appetite or poor appetite Loss of smell or taste ensation of lump in throat Stomachache Under weight or unable to gain weight c. Respiratory System Symptoms. Check all that apply. Chronic or frequent cough Cold sores Excess mucus production Frequent infections Hayfever and respiratory allergies Itchy nose or ears Post nasal drip Sinus headaches Sinusitis or chronic sinus congestion Wheezing or shortness of breath d. Circulatory System Symptoms. Check all that apply. Anemia Chest pain Cold hands and feet Family history of heart disease Gingivitis or gum disease Heart palpitations High blood pressure, specify blood pressure numbers: High cholesterol, specify: High triglycerides, specify: Irregular heart beat, arrhythmia Rapid heart beat Swelling in lower extremeties Varicose veins or spider veins Wounds that won t heal in the extremities Personal Health Evaluation, Page 4
5 e. Urinary and Fluid System Symptoms. Check all that apply. Bladder infections Blood in the urine Burning or painful urination Difficulty starting urination Excessive perspiration Frequent pale urine Frequent urination History of kidney stones Night sweats Pain in the mid to low back Puffiness under eyes Scant, dark urine Urinary incontinence (dribbling) Urinary tract infections (UTIs) Water retention or edema Swollen lymph nodes f. Glandular System Symptoms. Check all that apply. Burning sensations in hands and feet Cold hands and feet Dark circles under eyes Dry skin Excess weight Excess weight around the abdomen Fatigue in the afternoons Fatigue, chronic or excessive Feeling chronically stressed Feeling exhausted, burned-out Frequent thirst Hair loss or thinning Lack of stamina Loss of short-term memory Low body temperature, easily chilled Mental sluggishness, brain fog Mood swings Muddled thinking, confusion Restless disturbed sleep Restless dreams or nightmares Waking up at night unable to go back to sleep Waking up frequently at night Males Only Difficulty urination Erectile dysfunction Infertility Lack of sex drive Loss of self-confidence and drive Nighttime urination Prostate problems Urinating at night Females Only Cravings for chocolate with periods Depression with periods Edema or bloating associated with periods Heavy menstrual bleeding Hot flashes and/or night sweats Infertility Irritability with periods Lack of sexual desire Menstrual cramps Nursing (currently) Painful menstruation PMS Post-menopausal Pregnant (currently) Vaginal discharge Vaginal dryness Personal Health Evaluation, Page 5
6 g. Nervous System Symptoms. Check all that apply. Absent-mindedness Alcoholism Anxiety, nervousness Chronic muscle tension Difficulty getting to sleep Dizziness or light headedness. Excitability, difficulty relaxing Feeling depressed or discouraged Headaches Tension headaches with tight, constricted feeling h. Structural System Symptoms. Check all that apply. Acne Arthritis Back pain Brittle fingernails Eczema Gout Itching, skin Joint pain Leg cramps or pains Multiple root canals Pounding headaches (like head is exploding Headaches around eyes or forehead Migraines Loss of memory Panic attacks Peripheral neuropathy Poor concentration Shaky hands Muscle cramps Neck pain Osteoprosis Rashes Rosacea Stiff, aching or painful muscles Teeth grinding Tense muscles Weak legs, knees or ankles i. Add any additional information you feel may be helpful in evaluating your situation. Personal Health Evaluation, Page 6
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City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
MEDICAL QUESTIONNAIRE (male)
MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell
McKay Chinese Herbal Medicine & Acupuncture
McKay Chinese Herbal Medicine & Acupuncture Notice Receipt Acknowledgement ************************************************************************ Purpose: This form is used to confirm that an individual
All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge.
Nutritional Counseling Food Sensitivity Testing Neurotransmitter Testing Hormone Testing Wellness & Prevention 111 O Fallon Commons Drive O Fallon, MO 63368 Phone: 636-978-0970 Fax: 636-978-7570 Dr. Olivia
CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form
Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
Placer Private Physicians: Patient Health Questionnaire [2]
![Placer Private Physicians: Patient Health Questionnaire [2]](/thumbs/87/96006031.jpg "Placer Private Physicians: Patient Health Questionnaire [2]")
Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure