Client Intake and Health History
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- Jonathan Lambert
- 5 years ago
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1 Providence Wholistic Healthcare Sheila M. Frodermann, MS, ND, DHANP, CCH Carol L. Seng, MAOM, DA, LAc 144 Waterman Street, Suite #3 Providence, RI (401) Client Intake and Health History Name Date Address City State Zip Code Telephone # (home) (cell) Age Date of Birth Gender: Female Male Education Married Partnership Separated Divorced Widowed Single Live with: Spouse Partner Parents Children Friends Alone Occupation Hours per week Retired Employer Work phone contact Work address How did you hear about our clinic? Has any other family member already been a patient at the clinic? Next of Kin or other to reach in an emergency Relationship Phone Address HEALTH HISTORY QUESTIONNAIRE SUCCESSFUL HEALTH CARE AND PREVENTIVE MEDICINE ARE ONLY POSSIBLE WHEN THE PHYSICIAN HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND EMOTIONALLY. PLEASE COMPLETE THE FOLLOWING QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON'T UNDERSTAND WITH A QUESTION MARK. 1
2 History of Health Condition(s): When, where & from who did you last receive medical care or general health care? What was the reason? Did you get blood work? What kind of blood work? Please bring a copy for the Doctor. 1) 2) 3) 4) List your most important health problems in order of importance 5) _ 6) _ 7) 8) What is your general state of health (circle one): Excellent Good Average Fair Poor Are you currently seeing a primary care physician? Who? What are your diagnoses? Family History: indicate if you or a member of your close family have had the following Self Mother Father Brother Sister(s) Grandparents (MGP) (PGP) Cancer / / Diabetes / / Heart Disease / / High Blood Pressure / / Stroke / / Epilepsy / / Mental Illness / / Asthma/Allergies / / Anemia / / Kidney Disease / / Bowel Disease / / Ulcer / / Tuberculosis / / Osteoporosis / / Thyroid disease / / Age if living / / What is your nationality/ethnicity? Any known genetic risks 2
3 Your Health History Childhood Illnesses: Scarlet fever Diphtheria Rheumatic fever Mono Mumps Measles German measles Immunizations: Polio Pertussis Varicella Tetanus shot Diphtheria HPV Measles/Mumps/Rubella Other Any history of negative reactions to vaccination Hospitalizations and Surgeries X-Rays and Special Studies: X-rays, CAT scans, EKGs or other studies you have had: Allergies: Medications/drugs Environmentals Any Food sensitivities or allergies Current Medications: Do you take or use Laxatives Pain relievers Antacids Cortisone Appetite suppressants Antibiotics Tranquilizers Thyroid medication Sleeping pills MAO inhibitors Appetite suppressants Diuretics Stimulants ADHD medications Steroids Please list all prescription, OTC meds, vitamins & supplements you are taking & the dose? 1) 6) 2) 7) 3) 8) 4) 9) 5) 10 Typical Daily Food Intake Breakfast: Lunch: Dinner: Snacks Beverages DIGESTION Do you ever experience the following: Gas/bloating? Frequency Bowel movements/day Constipation? Diarrhea 3
4 Irritable bowel Bowel Disease Ulcers Heartburn Food, mucus or blood in your stool Abdominal pain Frequent nausea and/or vomiting Hemorrhoids Liver disease Gall bladder disease # Antibiotics/year WOMEN: FEMALE REPRODUCTION/BLADDER Age of last menses? Are cycles regular? Length of cycle? days Bleeding between cycles? Duration of menses? days Pain during intercourse? Painful menses? Clotting? Heavy or excessive flow? Discharge? PMS? Sexually active If yes, what are your symptoms? Birth control? Type: Number of pregnancies Number of live births Endometriosis? Number of miscarriages Ovarian cysts? Number of abortions Difficulty conceiving? Menopausal symptoms? Cervical Dysplasia? Last PAP Abnormal PAP Sexual difficulties? Chlamydia or other STD Any difficulty with urination? Lose urine/ incontinence Frequent urinary infections Urinary frequency Low libido Yeast infections Breast (circle): Pain Lumps Fibrocystic Lumpectomy Premenstrual tenderness Cancer Last Mammogram: Family history of breast/ovarian cancer Do you experience difficult urination MEN: PROSTATE AND URINARY HEALTH Difficulty starting stream Painful urination Prostate disease Forked stream Testicular pain Waking at night to urinate #/night Hernias Venereal disease Low libido Sexually active Sexual difficulties Erectile Dysfunction DAILY LIFESTYLE HABITS Do you exercise regularly? What form(s) & how often? Present Height Weight lbs. Weight 1 year ago lbs. Maximum Weight Date Desired weight lbs. When during the day is your energy the best worst Diet and lifestyle habits continued Average 6-8 hrs. sleep? Enjoy your work? Sleep well? Take vacations? Awaken rested? Spend time outside? Have a supportive relationship? Watch television? Have a history of abuse? how many hours/day Any major traumas? Read? Use recreational drugs? how many hours/day Treated for drug dependence? Do you eat three meals a day? Alcoholic drinks/ week History of drinking alcohol 4
5 Do you eat out often? Treated for alcoholism? Do you go on diets often? Use tobacco presently Coffee cups/day History of smoking Black or green tea cups/day how many years Soda/cola cups/day how many packs per day Any Artificial sweeteners in your diet? #/day Do you have a religious/spiritual practice? If yes, what? Main interests and hobbies How does your condition(s) affect you? What do you think is happening & why? What do you feel needs to happen for you to get better? What is the most important part of your healing process? What do you enjoy most in your life? Are you happy? What would you do to improve your life? _ Which of the following would you prefer to be included in your health plan? Dietary recommendations Stress management Exercise Vitamins/Minerals Other nutrients Herbs Homeopathy Hydrotherapy Bodywork Counseling Other 5
6 Providence Wholistic Healthcare Sheila M. Frodermann, MS, ND, DHANP, CCH Carol L. Seng, MAOM, DA, LAc 144 Waterman Street, Suite #3 Providence, RI (401) Client Intake and Health History Homeopathic Addendum - Review of Systems Name Date Address City State Zip Code Telephone # (home) (cell) Age Date of Birth Gender: Female Male Education Married Partnership Separated Divorced Widowed Single Live with: Spouse Partner Parents Children Friends Alone Occupation Hours per week Circle Y - a condition you have P - a condition you have had before N - never had this condition Skin: Respiratory: Warts Constriction Rashes Cough Eczema Sputum Acne, boils Spit up blood Itching Wheezing Color Change Asthma Lumps Bronchitis Night sweats Pneumonia Head: Pleurisy Headache Difficulty breathing Head injury Emphysema Eyes: Pain on breathing Impaired vision Shortness of breath Glasses/contacts -at night Eye pain -when lying down Tearing/dryness Tuberculosis Double vision Cardiovascular: Glaucoma Heart Disease Cataracts Angina Ears: High Blood Pressure Impaired hearing Murmurs Ringing Swelling in ankles Earaches Chest Pain Dizziness Palpitations Nose/Sinuses: Gastrointestinal: Frequent colds Liver disease Nose bleeds Heartburn Ulcers Stuffiness Hay fever Change in thirst Change in appetite
7 Sinus problems Nausea Mouth/Throat: Vomiting Frequent sore throat Vomit blood Canker sores Hemorrhoids Sore tongue Belching/gas Gum problems Gall bladder Disease Hoarseness Blood in stool Dental cavities Bowel movement, how often: Neck: Musculoskeletal: Lumps Joint pain or stiffness Swollen glands Arthritis Goiter Broken bones Pain or stiffness Muscle spasms/cramps Trouble Swallowing Weakness Urinary: Bone disease Pain on urination Osteoporosis Increased frequency Peripheral vascular: Frequency at night Deep leg pain Inability to hold urine Cold hands/feet Frequent infections Varicose veins Kidney stones Thrombophlebitis Female reproductive: Neurologic: Age menses began: Fainting Average # of days long: Seizures Total days in cycle: Paralysis Bleeding between Muscle weakness Are cycles regular Numbness/tingling Pain during intercourse Loss of memory Painful menses Emotional: Excessive flow Depression Birth control Mood swings Type: Anxiety/nervousness # of pregnancies: Tension # of live births: Endocrine: # of miscarriages: Hypothyroid # of abortions: Heat or cold intolerance Difficulty conceiving Excessive thirst Menopausal symptoms Excessive hunger Sexually active Blood problems Venereal disease Easy bruising Age Menses Ceased Anemia Breasts: Male reproductive: Self breast exam Prostate disease Testicular masses Lumps Hernias Testicular pain Pain or tenderness Nipple discharge Venereal disease Discharge or sore Sexually active Erectile dysfunction
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NEW PATIENT QUESTIONNAIRE
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Dr. Michelle Mackay Patel, ND
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Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
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Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
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Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM
Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of
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Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
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Scottsdale Family Health
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Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
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/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
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