BREAKTHROUGH MEDICINE
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1 Page1 BREAKTHROUGH MEDICINE SHAIDA SINA, NMD PRACTICE Patient Visit LOCATION: Location: 2530 W. ST. RT. 89A, Suite B1 Core Chiropractic Sedona, AZ W. SR 89A VIRTUAL Sedona, AZ OFFICE: PO Front BOX Office 208 and Natural Pharmacy: Cornville, AZ Breakthrough Medicine Ph: Cornville Road, Suite E, Fax: Cornville, AZ Phone: Fax: FEMALE HEALTH HISTORY INTAKE Last name: First: Middle: Age: Gender: Marital Status: Date of Birth: Reason for visit: Last Medical Visit (date & with whom) Please Check box if appropriate and note when it was performed. Thermal or Mammogram: Colonoscopy or Endoscopy: Bone Density: MRI/Cat Scan/Ultrasound/X-ray: General Blood Work: Dental Exam: Hormone Screen: Eye Exam: Allergies Reactions (Medicine and Substance): Please list: Dosage and Frequency of how you are taking Medications and Supplements Medications (over the counter and prescribed) Supplements (vitamins, amino, herbs.)
2 Page2 Family History: F = Father, M =Mother, S = Siblings, GP = Grandparents, C =Children Allergy: Cholesterol: Brain Issues: Prostate Issues: Anemia: Digestive Issues: Mental Illness: Thyroid Issues: Asthma: Diabetes: Heart Attack: Lung Issues: Blood Pressure: Female Issues: Stroke: Autoimmune: Cancer: Bone Loss: Eye Issues: Adrenal: List all Surgeries & Hospitalizations, including date occurred: Please note D = Disease, I = Immunized, N = Neither (also list most recent booster year) Small Pox: Rubella: Chicken Pox Measles: Tetanus: Pertussis (whooping cough): Mumps: Diphtheria: Haemophilus (HIB): Hepatitis A: Hepatitis B: Polio: Pneumococcal: Meningococcal: Influenza: Rotavirus: RSV: Human Papillomavirus: Please List All Reactions to Vaccinations: : List Y = Yes, N = No, P = Past regarding use of the following, if yes, note amount and how often: Antacids: Steroids: Antibiotics: Analgesics: Laxatives: Enema: Coffee: Alcohol: Soda: Candy/Cookies: Tobacco: Recreational Drugs: Present Height: Present Weight: Weight one year ago? Max. weight? When? Min. weight? When? Ideal Weight: Do you have good energy throughout the day? Explain:
3 Page3 Do you experience restful sleep? If you answered No, please explain: List last 10 years of type of work you have done: Are you chemically sensitive to odors? If Yes, explain: Are you chemically sensitive to odors? What are your hobbies? If "YES", explain: Do you use pesticides, herbicides, or other chemicals around your home? Exercise Routine (type and how often: ) Past Medical History: Please Check Box Arthritis Emphysema Cancer Anxiety Structural Injury Kidney Disease Allergies Low Blood Pres. Celiac Depression Hepatitis Gallbladder Disease Asthma High Blood Pres. Cohn s Disease Diabetes HIV / AIDS Migraines Alcoholism Diverticulitis GERD (heartburn) Bipolar Disorder Sinusitis Thyroid Issues Alzheimer s Addiction Colitis Insomnia Gout Parkinson s Bronchitis Schizophrenia Heart Murmur Glaucoma Lupus Osteoporosis or Osteopenia Chronic Fatigue Eating Disorder Heart Attack Cataract Multiple Sclerosis Pneumonia Cholesterol high Epilepsy/Seizure Angina Concussion Sojourns Syndrome Hemorrhoids Varicose Veins Bladder Issues Eczema Psoriasis Acne Other, not listed: Tuberculosis Female History: Please note: P = Past, C = Current, N = Never When was you last Female exam? Period Irregular Endometriosis Ovarian Cyst Uterine Cancer Menopause Heavy Period Fibrocystic Breast Vaginal Infection Ovarian Cancer Pregnancy # Fibroids PMS Breast Cancer Abnormal Pap Birth #
4 HEALTH PROFILE NAME DATE Rate each of the following symptoms upon your typical health profile for: Point Scale 0 Never or Almost never have the symptom 3 Frequently have it, effect is not severe 1 Occasionally have it, effect is not severe 4 Frequently have it, effect is severe 2 Occasionally have it, effect is severe HEAD HEADACHES DIGESTIVE NAUSEA, VOMITING FAINTNESS TRACT DIARRHEA DIZZINESS INSOMNIA CONSTIPATION BLOATED FEELING EYES WATERY OR ITCHY EYES HEARTBURN SWOLLEN, REDDENED OR STICKY EYELIDS BELCHING, PASSING GAS INTESTINAL / STOMACH PAIN BAGS OR DARK CIRCLES UNDER EYES BLURRED OR TUNNEL VISION (Does not include near or farsightedness) JOINTS/ PAIN OR ACHES IN JOINTS MUSCLES ARTHRITIS EARS ITCHY EARS STIFFNESS OR LIMITATION OF MOVEMEMENT EARACHES, EAR INFECTIONS DRAINAGE FROM EAR RINGING IN EARS, HEARING LOSS PAIN OR ACHES IN MUSCLES FEELING OF WEAKNESS OR TIREDNESS WEIGHT BINGE EATING/DRINKING NOSE STUFFY NOSE CRAVING CERTAIN FOODS SINUS PROBLEMS HAY FEVER SNEEZING ATTACKS EXCESSIVE MUCOUS FORMATION EXCESSIVE WEIGHT COMPULSIVE EATING WATER RETENTION UNDERWEIGHT MOUTH/ CHRONIC COUGHING ENERGY/ FATIGUE, SLUGGISHNESS THROAT GAGGING, FREQ. NEED TO CLEAR THROAT ACTIVITY APATHY, LETHARGY SORE THROAT, HOARSENESS, LOSS OF VOICE SWOLLEN OR DISCOLORED TONGUE, GUMS, LIPS CANKER SORES HYPERACTIVITY RESTLESSNESS MIND POOR MEMORY SKIN ACNE CONFUSION, POOR COMPREHENSION HIVES, RASHES, DRY SKIN HAIR LOSS FLUSHING, HOT FLASHES EXCESSIVE SWEATING POOR CONCENTRATION POOR PHYSICAL COORDINATION DIFFICULTY IN MAKING DECISIONS STUTTERING OR STAMMERING SLURRED SPEECH HEART IRREGULAR OR SKIPPED HEART BEAT LEARNING DISABILITIES RAPID OR POUNDING HEARTBEAT CHEST PAIN EMOTIONS MOOD SWINGS ANXIETY, FEAR, NERVOUSNESS LUNGS CHEST CONGESTION ANGER, IRRITABILITY, AGRESSIVENESS ASTHMA, BRONCHITIS SHORTNESS OF BREATH DEPRESSION DIFFICULTY BREATHING OTHER FREQUENT ILLNESS FREQUENT OR URGENT URINATION GRAND GENITAL ITCH OR DISCHARGE
5 FEMALE HORMONE SURVEY NAME DATE Please score: BLANK= No Symptoms. 1-5 ( 1=Mild 5=Severe ) Hot Flashes Night Sweats Irritability Mood Swings Weepy Irregular Periods Heavy Periods Bleeding between periods Low sex drive Lumpy breasts Unable to reach orgasm Painful intercourse Lack of vaginal lubrication Breast tenderness Drooping breasts Sleep problems Anxiety or panic attacks Depression Loss of motivation Feeling apathetic Fatigue Memory loss Thinning hair Dry skin Cellulite Decreased muscle strength Fluid retention Headache Joint pain Muscle pain Urinary incontinence Acne Facial hair growth Constipation Food Cravings Vaginal Discharge Vaginal Itching
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