Dr. Michael Nichols, DC 4027 Allston St. Dr. Julie Nichols, DC Cincinnati, OH Nutrition Intake Form

Transcription

1 Gateways to Healing Family Wellness Center Dr. Michael Nichols, DC 4027 Allston St. Dr. Julie Nichols, DC Cincinnati, OH Nutrition Intake Form General Information Name Date Address City State Zip Code Home Phone Cell Phone Age DOB Place of Birth Gender: female male Married Separated Divorced Widowed Single Partnership Do you have any children? Yes No If so, how many? Ages Gender(s) Occupation Nature of Business How did you hear about our office? Has another family member been a patient at our office? Who is your primary physician? Have you ever traveled outside of the U.S.? Yes No If yes, when and where? Have you or your family recently experienced any major life changes? Yes No If yes, please explain Have you experienced any major losses in life? Yes No If yes, please explain Do you have any allergies? Yes No If yes, what are you allergic to and what is your reaction?

2 Complaints / Concerns Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptom has been present. (use the back of this page if necessary.) PROBLEM ONSET FREQUENCY SEVERITY What diagnosis (if any) or explanation have you been given for any of the above issues? When was the last time you felt well? Do you recall any particular event being the cause in your change of health? What makes you feel worse? What makes you feel better? Please list all of the physicians you have seen for any of the health conditions listed above: HOSPITALIZATIONS Where Hospitalized When For What Reason

3 PAST MEDICAL & SURGICAL HISTORY ILLNESSES PAST ONGOING COMMENTS Chicken Pox German Measles Measles Mumps Whooping Cough Anemia Arthritis Asthma Bronchitis Cancer Chronic Fatigue Chrohn s Disease Diabetes Emphysema Epilepsy (convulsions) Gallstones Gout Heart Attack/Angina Heart Failure Hepatitis High Blood Pressure Irritable Bowel Kidney Stones Mononucleosis Pneumonia Rheumatic Fever Sinusitis Sleep Apnea Stroke Thyroid Disease

4 Ulcerative Colitis Other (please describe) DIAGNOSTIC STUDIES DATE(S) COMMENTS Chest X-ray Mammogram EKG Sigmoid/Colonoscopy Upper GI Series Barium Enema CAT Scan/MRI/X-rays Bone Scan Bone Density Test Carotid Artery Ultrasound Other (please describe) OPERATIONS DATE(S) COMMENTS Tonsillectomy Tubes in Ears Appendectomy Gall Bladder Hernia Hysterectomy Other (please describe) CHILDHOOD HEALTH HISTORY As a child, were there any foods that you had to avoid because they gave you symptoms? Yes No If yes, please name the food and symptom (e.g. wheat - gas and bloating) FOOD SYMPTOM OTHER COMMENTS

5 MEDICATIONS & SUPPLEMENTS MEDICATION LOG Please indicate the type of medications you are now taking. Please include non-prescription drugs. Medication name Date Started Date Stopped Dosage # per day SUPPLEMENT LOG Please list all vitamins, minerals, herbs and other nutritional supplements. Supplement Name and Brand Date Started Dosage Frequency Reason for Use

6 VACCINE HISTORY Have you ever had an adverse reaction to a vaccine? Yes No If yes...which vaccine Date of the vaccine Was your reaction Immediate (within hours) Delayed (up to two weeks) Describe your reaction symptoms (loss of speech, seizure, paralyzation, illness, rash, etc.) Date and name of recent vaccines, if any FEMALE MEDICAL HISTORY (for women only) OBSTETRICS HISTORY Check box if yes and provide number of Pregnancies Caesarean Vaginal deliveries Miscarriage Abortion Living children Postpartum depression Toxemia Gestational diabetes Baby over 8 pounds Breast feeding? If yes, how long? GYNECOLOGICAL HISTORY Age at 1st period: Menses Frequency: Length : Pain: Yes No Clotting: Yes No Has your period skipped? For how long? Do you currently use contraception? Yes No If yes, what type? Condom Diaphragm IUD Patch Partner vasectomy Birth control pills If yes, does it agree with you? Yes No Nuva ring How Long? In the 2nd half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)? Yes No Last Mammogram/Thermogram Breast biopsy/date Last PAP test: Normal Abnormal Date of last bone density: Results: High Low Within normal range Are you in menopause? Yes No Age at menopause Do you take: Estrogen Provera Ogen Estrace Premarin Progesterone Other How long have you been on hormone replacement? Have your medications or supplements ever caused you unusual side effects or problems? Yes No

7 If yes, please describe: FAMILY MEDICAL HISTORY Please mark any health problem(s) your family has suffered with either now or in the past: F = Father, M= Mother, B = Brother, S = Sister, C = Children, MGM = Maternal Grandmother, MGF = Maternal Grandfather, PGM = Paternal Grandmother, PGF = Paternal Grandfather, A = Aunt, U = Uncle, O = Other Check family members that apply F M B S C MGM MGF PGM PGF A U O Age (if still alive) Age at death (if deceased) Heart attack Stroke Cancer (Specify type) ADD/ADHD ALS Alzheimer s Anemia Anxiety Arthritis (Specify type) Asthma Autism Autoimmune diseases Bladder disease Blood clotting problems Celiac disease Dementia Depression Diabetes (Specify I or II) Eczema Emphysema Epilepsy Genetic disorders Glaucoma High blood pressure Bowel disease Insomnia Kidney disease Multiple sclerosis

8 Obesity Osteoporosis Parkinson s Pneumonia/Bronchitis Psoriasis Psychiatric disorders Sleep anema Smoking addiction Ulcers Any other family history we should know about? Yes No If yes, please comment: NUTRITION & 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 Low Fat Low Starch/Carbohydrate Mixed Food Diet (Animal and vegetable Sources The Blood Type Diet High Protein/Paleo Metabolic Typing Diet Vegetarian Total Calorie Restriction Vegan Diabetic Gluten Free No Dairy Low Sodium No Wheat GAPS Diet Specific Program for Weight Loss/Maintenance Type: Height (feet/inches) Current Weight Usual weight range +/- 5 lbs. Desired weight range +/- 5 lbs. Highest adult weight Lowest adult weight Are there any foods that you avoid because they give you symptoms? Yes No If yes, please name the food and the symptom (e.g. wheat- gas and bloating) FOOD SYMPTOMS Other comments

9 Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc? Yes No If yes, please explain: EXERCISE Current exercise program: Activity (list type, number of sessions/week, and duration of activity) ACTIVITY TYPE Frequency per week Duration in minutes Stretching Cardio/Aerobics Strength Training Other (Pilates, yoga, etc ) Sports or leisure activities List problems that limit activity: Do you feel fatigued after exercise? Yes No Do you usually sweat when exercising? Yes No SOCIAL HISTORY SLEEP/REST Average number of hours you sleep Do you have trouble staying asleep? Do you have trouble falling asleep? Do you have rested sleep? Do you feel rested upon awakening? Do you snore? Yes No Yes No Yes No Yes No Yes No TOBACCO HISTORY Currently using tobacco? Yes No How long? What type? Cigarette Packs per day: Smokeless Cigar Pipe Patch/gum Previous smoking: How many years? Packs per day: ALCOHOL INTAKE How many drinks currently per week? 1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits

10 None >10 Previous alcohol intake? Yes No ( Mild Moderate High) A Personal Message As we prepare to begin this journey towards better health and wellness for you, there are some important things I would like to discuss before we start. After many years working with individuals on achieving their health goals, I have found certain patterns and reasons that have determined whether a person succeeds in achieving their goals or ends their journey in frustration. Part of this is based on the motivations that drive you toward achieving the particular goal. To help in setting up the best start for you towards accomplishing your goals, I would like to ask you some very important questions. It is equally important that you answer these questions with complete honesty and really look deep within yourself for the answers. What are you hoping to achieve by working with us? If you could change or take away any three issues, what would they be? Have you actually made the decision to change and do whatever it takes to get well? Yes No Please list 3 things you have been unable to do as a result of your present situation. Be specific Are there any other health goals you would like to achieve? Thank you for taking the time to fill out these questions. Your answers provide very valuable information that will allow us to discover the missing piece to your puzzle that will solve your particular health problem. Once all the forms have been completely filled out, please return them to our office and we will then make an appointment for your initial consultation. Thanks once again for entrusting us with helping you to achieve your health goals.