Naturopathic Intake Form PERSONAL MEDICAL HISTORY

Transcription

1 List any surgeries, hospitalizations, imaging (CT, MRI, EEG, EKG, etc.) Date MM/YY ALLERGIES Do you have any allergies to medications? [ ] Yes [ ] No If yes, list medication and reaction Do you have any food or environmental allergies or sensitivities (ie, dairy, pollen, etc)? [ ] Yes [ ] No [ ] unknown. If yes, list allergy and reaction IMMUNIZATION HISTORY [ ] Polio [ ] Pertussis [ ] Hepatitis A [ ] Hepatitis B [ ] HIB [ ] Diphtheria [ ] Chicken pox [ ] Tuberculosis [ ] Flu shot Date? [ ] s CHILDHOOD ILLNESS: CIRCLE ANY THAT APPLY Chicken Pox Mononucleosis Rubella German Measles Diphtheria Strep Throat Tuberculosis Scarlet Fever LIST RECENT PREVENTATIVE SCREENING TESTS: Test (CBC, lipids, etc) Date Result Sigmoidoscopy Normal [ ] Abnormal [ ] Colonoscopy Normal [ ] Abnormal [ ] Pap smear Normal [ ] Abnormal [ ] Mammogram Normal [ ] Abnormal [ ] Dexascan Normal [ ] Abnormal [ ] PSA (prostate) Normal [ ] Abnormal [ ] : Normal [ ] Abnormal [ ] Page1 Name: D.O.B

2 SOCIAL HISTORY With whom do you live and for how long? Do you have a religious or spiritual practice? [ ] Yes [ ] No If yes, please explain: Do you have any pets that live in the home with you? [ ] Yes [ ] No Describe: How often do you take vacations? Do you exercise? [ ] Yes [ ] No If yes, what type(s): minutes/day & days/week Are you satisfied with your sex life? [ ] Yes [ ] No DIET Do you follow a particular diet (ie, vegan, vegetarian, gluten-free, dairy-free, etc.)? [ ]Yes [ ] No If yes, Please describe what you typically eat: Breakfast Lunch Dinner Snacks/desserts Beverages: Please indicate the amount consumed per day and circle Cups or Ounces Water Coffee Tea (Black, herbal, other) Soda Juice Do you have any concerns about your relationship to your body and/or food or exercise that you would like to talk about at some point? [ ] Yes [ ] No On the scale below please rate your satisfaction with your body. 1 is no satisfaction, 10 is 100% satisfaction Do you have an eating disorder or a history of eating disorder? [ ]Yes [ ]No If yes, please describe Do you have a history of yo-yo dieting? [ ] Yes [ ] No Have you had large weight variances that were not due to a medical condition? [ ] Yes [ ] No If yes, please describe Page2 Name: D.O.B

3 Smoke Cigarettes: [ ] Never smoked [ ] Yes, in the past. Date quit: Years of use: [ ] Yes, currently Packs per day: tobacco use: [ ] Pipe/Cigar/Chew/Snuff Years of Use: Tobacco exposure: [ ] Second-hand smoke Years of exposure: Do you drink alcohol? [ ] Never [ ] Past [ ] Currently Number of drinks/wk: Have you been treated for alcoholism? [ ] Yes [ ] No Have you ever used recreational drugs? [ ] Yes [ ] No If yes, please explain Age (if living) Age (at death) Cause of death Anemia Asthma Hay fever, Hives Cancer Diabetes Epilepsy Glaucoma High Blood Pressure Kidney Disease Mental Illness Stroke Tuberculosis : Answer or check those applicable: Father Mother Brothers Sisters Spouse Children REVIEW OF SYSTEMS For the following please circle: Y = Yes/Current issue N = No/Never had P = Past problem Page3 Name: D.O.B

4 MENTAL/EMOTIONAL Depression P Mood Swings P Anxiety/Nervousness P Tension P Memory Problems P Poor Concentration P Considered suicide P Attempted suicide P SKIN Rashes P Itching P Changes in skin color P Acne/boils P Eczema P Lumps/bumps P Hair Loss P HEAD Headaches P Head P Injury P Jaw issues or TMJ P NECK Lumps in neck P Swollen Glands P Goiter P Pain or Stiffness in neck P EYES Impaired Vision P Glasses or Contacts P Eye Pain or strain P Tearing or dryness P Double Vision P Glaucoma P Cataracts P Color blindness P EARS Impaired hearing P Ringing in ears P Earaches P History of ear infections P NOSE, THROAT, MOUTH Stuffy Nose P Frequent Colds P Frequent sore throats P Sinusitis P Hoarseness P Sore Tongue or lips P Gum Problems P Tooth Problems P Teeth grinding P RESPIRATORY Cough P Excess Sputum P Coughing up Blood P Wheezing P Asthma P Page4 Name: D.O.B

5 RESPIRATORY CONT. Bronchitis P Pneumonia P Pleurisy P Emphysema P Pain with Breathing P Shortness of Breath P -Lying down? P Tuberculosis P CARDIOVASCULAR High Blood Pressure P Heart Disease P Angina P Chest Pain P Murmurs P Rheumatic Fever P Swelling in ankles P Palpitations, Fluttering P PERIPHERAL VASCULAR Deep Leg Pain P Cold Hands and Feet P Varicose Veins P Thrombophlebitis P BLOOD Anemia P Easy Bleeding or Bruising P Previous Blood Transfusion P GASTROINTESTINAL Trouble Swallowing? P Change in Thirst P Change in Appetite P Nausea P Vomiting P Vomiting Blood P Frequency of Bowel Movements: Times Each Day Is this a change? P Blood in Stool P Black stools P Diarrhea P Constipation P Abdominal pain or cramps P Heartburn P Belching or passing gas P Jaundice (yellow skin) P Liver Disease P Gall Bladder Disease P Ulcer P Hemorrhoids P URINARY Pain on Urination P Increased Frequency P Frequency at Night P Inability to hold urine P Frequent infections P Kidney Stones P Page5 Name: D.O.B

6 NEUROLOGIC Fainting P Vertigo or Dizziness P Seizures P Paralysis P Muscle Weakness P Numbness/Tingling P Loss of Memory P Loss of Balance P ENDOCRINE Hypothyroid P Heat/Cold Intolerance P Excessive Thirst P Excessive Hunger P Fatigue P Hyperthyroid P Diabetes P -Type 1 or 2? 1 2 Seasonal depression P MUSCULOSKELETAL Joint Pain or Stiffness P Arthritis P Broken Bones P Muscle Spasms P Weakness P Sciatica P IMMUNE Reactions to vaccines P Persistent swollen glands P Slow wound healing P Chronic fatigue P Chronic infections P Night sweats P BREASTS Do you perform self-exams? P Breast Lumps P Pain or Tenderness P Nipple discharge P FEMALE REPRODUCTIVE Are you sexually active? P Sexual orientation: Birth control? P Do you use it every time? STI protection? Do you use it every time? Regular partner(s)? Age of first Menses Age of Last Menses (if menopausal): Date of last Pap smear: Abnormal Pap smear? If yes, date: Duration of Menses: DAYS Length of Cycle: DAYS Regular Cycles P Bleeding Between Periods P Painful Menses P Excessive/Heavy Flow P PMS P If so, what symptoms? Page6 Name: D.O.B

7 FEMALE REPRODUCTIVE CONTINUED Pain with Intercourse P Sexual Difficulties P Difficulty Conceiving P Number of Pregnancies: Number of Live Births: Number of Miscarriages: Number of Abortions: Menopausal Symptoms P Vaginal odor P Vaginal Discharge P Endometriosis P Ovarian Cysts P Gonorrhea P Chlamydia P Genital P Warts P Herpes P Syphilis P MALE REPRODUCTIVE Are you sexually active? Sexual orientation: Birth control? Do you use it every time? STI protection? Do you use it every time? Do you have regular partner(s)? Hernias P Testicular Masses P Testicular Pain P Penile Discharge or Sores P Gonorrhea P Chlamydia P Genital Warts P Herpes P Syphilis P Prostate Disease P What Type? Impotence P Premature Ejaculation P Page7 Name: D.O.B