MEDICAL HISTORY. Laboratory procedures performed: (e.g. stool analysis, blood and urine chemistries, hair analysis) Outcome
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1 Click in the NAME field and complete form. Use TAB to move to next field. SAVE form and then SEND TO or to Or you can PRINT and bring with you at your first appointment. MEDICAL HISTORY Name Date Street Address City ST ZIP ` Home phone Cell phone Work Phone Height Weight Date of Birth Marital Status Blood Type Occupation Age Sex # of Children address: Reason for today s office visit: List current health problems for which you are being treated: What types of therapies have you tried for these problems or to improve your health over-all: Diet modification Fasting Vitamins/minerals Herbs Homeopathy Chiropractic Acupuncture Conventional medications Other Do you experience any of these general symptoms EVERY DAY? Debilitating fatigue Shortness of breath Insomnia Constipation Depression Chronic pain Panic attacks Nausea Fecal incontinence Bleeding Disinterest in sex Headaches Vomiting Urinary incontinence Discharge Disinterest in eating Itching/rash Diarrhea Low grade fever Dizziness Current medications (prescription or over-the-counter): Laboratory procedures performed: (e.g. stool analysis, blood and urine chemistries, hair analysis) Outcome Major hospitalizations, surgeries, injuries: Please list all procedures, complications (if any) and dates: Year Surgery, illness or injury Outcome Rate your level of stress with 1 being the least stressed and 10 being the most stressed: Identify the major causes of stress (e.g. changes in job, work, residence or finances, legal problems) Do you consider yourself: underweight overweight just right My goal weight is Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months? Is your job associated with potentially harmful chemicals (e.g. pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g. fireman, etc.)? What are your current health goals:
2 Place an "X" next to those that that apply to you. Medical History arthritis allergies/hay fever asthma alcoholism Alzheimer s Autoimmune Blood pressure problems Bronchitis Cancer Chronic fatigue syndrome Carpal tunnel syndrome Cholesterol, elevated Circulatory problems Colitis Dental problems Depression Diabetes Diverticular Eating addiction Epilepsy Emphysema Eyes, ear, nose, throat, problems Environmental sensitivities Fibromyalgia Food intolerance Gastroesophageal reflux Genetic disorder Glaucoma Gout Heart Infection, chronic Inflammatory bowel Irritable bowel syndrome Kidney/bladder Learning disabilities Liver/gallbladder (stones) Mental illness Mental retardation Migraine headaches Neurological problems (Parkinson s, paralysis) Sinus problems Stroke Thyroid trouble Obesity Osteoporosis Pneumonia s Seasonal affective disorder Skin problems Tuberculosis Ulcer Urinary tract infection Varicose veins Other Medical (Men) Benign prostatic hyperplasia Prostate cancer Decreased sex drive Medical (Women) Menstrual irregularities Endometriosis Fibrocystic breasts Fibroids/ovarian cysts Premenstrual syndrome (PMS) Breast cancer Pelvic inflammatory Vaginal infections Decreased sex drive Other Date of last OB/GYN exam PAP Exam # of children # of pregnancies C-section Age of first period Date of last menstrual cycle Length of cycle days Interval of time between cycles days Any recent changes in normal menstrual flow (i.e. heavier, scanty) Surgical menopause Menopause Family Health History (Parents & Siblings) Arthritis Asthma Alcoholism Alzheimer s Disease Cancer Depression Diabetes Eating Disorder Eating disorder Genetic disorder Glaucoma Heart Learning disabilities Mental illness Mental retardation Migraine headaches Neurological disorders (Parkinson s, paralysis) Obesity Osteoporosis Stroke Suicide Other Health Habits Cigarettes: #/day Cigars: #day Wine: #glasses/day Liquor: #ounces/day Beer: #glasses/day Coffee:#6oz cups/day Tea:#6 oz cups/day Soda w/caffeine:#/day Water:#glasses/day Exercise 5-7 days per week 3-4 days per week 1-2 days per week 45 min or more per Workout min per workout Less than 30 minutes Walk: # days/wk Run, jog, other aerobic #days/week Weights:#days/wk Stretch:#days/wk Other Nutrition and Diet Mixed food diet (animal and vegetable sources) Vegetarian Vegan Salt restriction Starch/carb restriction The Zone Diet Total calorie restriction Specific food restrictions: i.e., dairy, wheat, soy, egg, gluten. Food Frequency Number of servings/day: Fruits Dark green vegetables Yellow/orange Grains (unprocessed) Beans, peas, legumes Dairy, eggs Meat, poultry, fish Eating Habits Skip meals; which ones One meal/day Two meals/day Three meals/day Graze (small, frequent meals) Generally eat on the run Eat constantly whether hungry or not Current Supplements Multivitamin/multimineral Vitamin C Vitamin E EPA/DHA Evening Primrose/GLA Calcium Magnesium Minerals, describe Zinc Probiotics (acidophilus) Digestive enzymes Amino acids CoQ10 Antioxidants Herbs Homeopathy Protein shakes Liquid meals (Ensure) Other I Would Like To: ENERGY VITALITY Feel more vital Have more energy Have more endurance Be less tired after lunch Sleep better Be free of pain Get fewer colds and flu Get rid of allergies Not be dependent on over-the-counter medications Stop using laxatives and stool softeners Improve sex drive BODY COMPOSITION Lose weight Burn more body fat Be stronger Have better muscle tone Be more flexible STRESS Learn how to reduce stress Think more clearly and be more focused Improve memory Be less depressed Be less moody Be less indecisive Feel more motivated LIFE ENRICHMENT Reduce my risk of degenerative Slow down accelerated aging Maintain a healthier life for a longer time Change from treating illness to creating a wellness lifestyle Making Lifestyle Changes I am comfortable with making large changes quickly I prefer to make small changes at first I am willing to change my diet immediately if it will make me feel better I prefer to make small changes in my diet each week I have taken supplements before and am comfortable taking a variety of items/day. I would prefer to start with just a few items I can easily work the cost of supplements and office visits into my budget and want to start with the fastest program possible My budget will allow me to spend $200 - $400 per month on supplements and office visits I need to keep the cost below $200 each month
3 ADRENAL FATIGUE QUICK CHECK Name: Date: Rate the following from 0 to 5, with 0 being no problem and 5 being a severe problem. Difficulty getting up in the morning Continuing fatigue, not relieved by sleep and rest Lethargy, lack of energy to do normal daily activities Sugar cravings Salt cravings Allergies Digestion problems Increased effort needed for everyday tasks Decreased interest in sex Decreased ability to handle stress Increased time needed to recover from illness, injury or traumas Light-headed or dizzy when standing up quickly Low mood Less enjoyment or happiness with life Increased PMS Symptoms worsen if meals are skipped or inadequate Thoughts are less focused; brain fog Memory is poorer Decreased tolerance for stress, noise, disorder Don't really wake up until after 10 A.M. Afternoon low between 3:00 P.M. and 4:00 P.M. Feel better after supper Get a "second wind" in the evening, and stay up late Decreased ability to get things done; less productive Have to keep moving; if I stop, I get tired Feeling overwhelmed by all that needs to be done It takes all my energy to do what I have to. There's none left over for anything or anyone else. TOTAL =================================================================================== suggests mild adrenal stress suggests moderate adrenal fatigue Over 70 suggests significant adrenal fatigue problems
4 Name METABOLIC SCREENING QUESTIONNAIRE Rate each of the following symptoms based upon your typical health profile: POINT SCALE 0 = Never or almost never have the symptom 3 = Frequently have it, effect not severe 1 = Occassionally have it, effect not severe 4 = Frequently have it, effect is severe 2 = Occassionally have it, effect is severe HEAD Headaches Faintness Dizziness Insomnia NOSE Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus EYES Watery or itchy eyes Swollen, reddened or sticky eyelid Bags or dark circles under eyes Blurred or tunnel vision (does not include near or far-sighted) MOUTH/THROAT Chronic coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice LUNGS Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing ENERGY/ACTIVITY Fatigue Apathy, lethargy Hyperactivity Restlessness EMOTIONS Mood swings Anxiety, fear, nervousness Anger irritability, agressiveness Depression
5 Kay Spears, Nutritionist ================================================================== Statement of Commitment: I fully understand that a healthy lifestyle requires commitment and dedication, and change doesn t happen overnight. I choose to improve my health by assuming greater self-responsibility to reduce or eliminate unhealthy behaviors that are contrary to my well-being. The Surgeon General (1990) estimated that 7 out of 10 of the leading causes of death in America are related to lifestyle habits. I will commit to Kay s recommendations for the agreed upon time frame and make my health my priority. No Guarantees: I am aware that no practice of medicine is an exact science, and acknowledge that there are and can be no guarantees as to accuracy or outcomes of any treatments/recommendations I receive. Cancellation Policy: As a client, you must cancel a scheduled appointment by 9:00 p.m. the prior night of the appointment to avoid a cancellation fee. If you cancel the same day or do not show, you will be charged a $25 no show fee. Payment Policy: Payment in full is required when services are rendered. Credit cards and checks accepted. Payment plans can be arranged only in extreme circumstances. client signature and date
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Integrative Consult Patient Background Form
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Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
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New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
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PERSONAL HEALTH HISTORY FORM DEMOGRAPHIC INFORMATION Name (last, first, middle initial) Social Security Number Birth date
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Saleeby Chiropractic Centre, P.A.
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Teresa McCurry, C.N.H.P. Passionate Health, 101 Old Mountain Rd., Powder Springs, GA 30127 Fax: 888 289 2171 PERSONAL HEALTH INVENTORY NAME DATE ADDRESS CITY, STATE, ZIP, COUNTRY HOME PHONE WORK PHONE
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