Rockwood Natural Medicine Clinic

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1 Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about our clinic? When did you have your last health care visit? What was the reason? Please list in order of importance your health problems: Family History Y = yes N = no P = past Has any family member had the following: If yes, please identify family member: Anemia Asthma Cancer Diabetes Epilepsy Glaucoma Heart Disease High Blood Pressure Kidney Disease Mental Illness Pneumonia Stroke Tuberculosis Venereal Disease Were any of these a cause of death? If so, which family member and at what age? Childhood Illnesses: Scarlet Fever Y N Diphtheria Y N Rheumatic fever Y N Mumps Y N Measles Y N German measles Y N

2 Immunizations: Polio Y N Diphtheria Y N Rubella Y N Measles/Mumps ertussis Y N Hepatitis B Y N Pneumonia Y N Small pox Y N Anthrax Y N Tetanus Y N Date of last tetanus shot: Allergies: What drugs a re you allergic to? What foods? Environmental allergies? Have you ever been hospitalized? Y N If yes, when and for what reason: Have you had any surgeries? Y N If yes, when and for what reason: Current Medications: Appetite suppressants Y N Laxatives Y N Tobacco Y N Antacids Y N Pain reliev ers Y N Tranquiliz ers Y N Birth control pi lls Y N Sleeping pills Y N Thyroid Y N Cortisone Y N Please list any prescription medication s, over-the-counter medic ines, vitamins or other supplements you are currently taking: Skin Acne Boils Color Changes Eczema Hives Itching Lumps Moles Rashes Scaling ***** Head Hair loss Headaches Head injury Skull fracture ****** Eyes Eye pain Cataracts Double vision Dryness Vision aids Glaucoma Impaired vision Tearing

3 Ears Discharges Earaches Dizziness Impaired hearing Ringing Trauma to ear ****** Nose & Sinuses Frequent colds Hay fever Nose bleeds Sinus pain Stuffiness Persistent running Trauma to nose Polyps ****** Mouth & Throat Bleeding gums Difficulty swallowing Cavities Frequent sore throat Hoarseness Sore tongue Ulcerations Difficulty speaking ******* Neck Goiter y N P Lumps Pain or stiffness Swollen glands Trauma to neck Thyroid medication ** ***************** *************************** Respiratory Asthma Bronchitis Cough Emphysema Pleurisy Difficulty breathing Pneumonia Pain with breathing Sputum Shortness of breath Tuberculosis with lying down Wheezing with exertion Blood in sputum at night

4 Cardiovascular Angina Chest pain High blood pressure Dizziness Heart disease Murmurs Palpitations/fluttering Leg pain w ith walking Rheumatic fever Ankle swelling ******* Gastrointestinal Belching Blood in stool Change in appetite Change in thirst` Gallbladder disease Heartburn Gas/bloating Hemorrhoids Liver disease Jaundice/yellow skin Vomiting vomiting of blood Ulcers Bowel movements: How often: Is this a change: Y N ***************** ************************* Urinary Frequent infections Frequency at night Increased frequency Inability to hold urine Kidney stones Kidney pain Pain with urination Urethral discharge ******** Endocrine/Blood Anemia Excessive thirst Easy to bleed/bruise Heat/cold intolerance Excessive hunger Low energy/fatigue

5 Female Reproductive System Age menses began: Birth control Average number of days: What type: Length of cycle: Number of pregnancies: Are cycles regular Number of live births: Do you have: Number of miscarriages: Painful menses: Number of abortions: Pain with intercourse Difficulty conceiving Excessive flow Menopause symptoms Premenstrual syndrome History of Venereal Dz ****************************** Are you sexually active Breasts Sexual difficulties Do you do self e xams Lumps Nipple discharge Breast pain Skin discoloration ***** Male Reproductive System Hernias Are you sexually active Testicular pain Sexual difficulties Testicular masses Prostate disease/pain Discharges or sores Venereal disease Musculoskeletal Joint pain/stiffness Broken bones Swelling of joints Muscle cramps/spasm Arthritis Weakness Peripheral Vascular Coldness of hands/feet Varicose veins Deep leg pain Spider veins Numbness of hands/feet Thrombophlebitis

6 Neurological Dizziness Numbness or tingling Fainting Memory loss Seizures Paralysis Mental/Emotional Anxiety or nervousness Excessive fears Depression Mood swings Excessive anger Tension/stress Habits Do you awake rested What are your main hobbies/interests? Sleep well Average hours of sleep: Enjoy your work What forms of exercise do you get? Watch television How many hours/day Work at a computer How many hours/day Exercise how often? Read How many hours/day Take vacations Have you been treated for: Do you use: Alcohol dependence Recreational drugs Drug dependence Alcoholic beverages ******************** Infants & Small Children Does your child: Eat well Sleep through the night Frequent earaches Frequent sore throats Diarrhea Constipation Colic Hyperactive Lethargic Constant runny nose Irritable Skin rashes Abnormal weight loss/gain Behavioral problems Reaction to vaccinations

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