INTEGRATIVE MEDICINE CONSULTATION INTAKE FORM. We look forward to working with you to achieve your optimal health and well- being!
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1 University of Florida Physicians PO Box UF Health Integrative Medicine - Executive Health Gainesville, Fla (352) 265- WELL (352) fax INTEGRATIVE MEDICINE CONSULTATION INTAKE FORM The following questions are designed to help us understand your overall health and well- being, address your health concerns, and identify your health goals. Since the integrative approach seeks to know the whole person, you will find questions to ascertain your physical, emotional, mental, and spiritual health in addition to information about your medical condition/s. If you cannot respond to some questions at this time, but would like to discuss this at future visits, or if you have other information to share that hasn t been covered, please indicate so at the Other Information section at the end of the form. In order to optimize your clinic visit time with us, we request that you complete this form and bring it with you to your appointment. The information you provide and those gathered from your clinic visit will be used to create your integrative health care plan. We look forward to working with you to achieve your optimal health and well- being! GENERAL INFORMATION Name: DOB: Primary Care Physician: Complementary and alternative medicine (CAM) providers: Other healthcare providers you regularly see (please list): Please list the health concerns you d like to be addressed at this visit. Begin with the most important one first. Does anyone else close to you have any concerns about your health other than what you have listed? No If yes, please provide more information: What would you like to get out of today s visit? Please list three health goals you d like to achieve within the next 12 months:
2 MEDICAL HISTORY Medical Diagnosis Onset (beginning date) Treatment received or receiving Injuries, Surgeries, Hospitalizations, etc. Onset (beginning date) Treatment received or receiving Please list all prescription medications that you are currently taking Name of Medication Dosage Reason for taking Frequency Please list over the counter medications, supplements, herbs, and/or homeopathic remedies that you are currently taking Name of Medication Dosage Reason for taking Frequency Please list treatments, medications, supplements, and/or herbs you ve used in the past that have not worked Name of Schedule of Date treatment/medication Duration of treatment/use Treatment/Medication treatment/dosage discontinued ALLERGIES/ SENSITIVITIES Medications Supplements/Herbs Food Environment (grasses, pollen, animal dander, etc.)
3 FAMILY HISTORY Please list any health problems with your Mother Father Sister/s Brother/s Grandparents Other REVIEW OF SYSTEMS General No - Difficulty Sleeping No - Low energy No - Hyperactivity No - Restlessness No - Feel too hot or too cold No - Excessive weight loss/gain Cardiovascular (Heart) No - Chest Pain No - High blood pressure No - Fainting No - Irregular heartbeats No - Rapid or pounding heartbeats Pulmonary (Lungs) No Shortness of breath No Chest Congestion No Wheezing Neurological No Headaches No - Numbness No - Dizziness No - Weakness No Difficulty Walking No - Falling No Poor Memory No Poor Coordination No Speech difficulties No Difficulty concentrating/focus Stomach and Intestines No Heartburn No - Constipation No - Diarrhea No - Cramping No Blood in stool No - Gas No Bloating No Nausea No Vomiting No Early feeling of fullness
4 Skin No Rashes No Itching No - Dryness No Excessive Sweating No Hair Loss No Acne Muscles, Joints and Bones No Joint Pain No Stiffness No Joint Swelling No Muscle pain or spasm Ears, Nose and Throat No Hearing loss No - Ringing in ears No Allergy No Sinus congestion No Difficulty swallowing No - Stuffy nose No Excessive sneezing No Chronic coughing No Gagging/frequent throat clearing Vision No Blurred No Seeing double No Seeing spots Mood No Sad No Anxious No Worried No Tense No Stressed No Hopeless No Angry outbursts No Irritability No Mood swings Urinary No Incontinence (trouble holding water) No Difficulty starting urination No Burning when urinating No Frequency, urgency (have to go to the bathroom often) Sexual function No Poor desire No Trouble having orgasm No Pain during sexual activity
5 For Women Only: Do you menstruate? No If yes, what was the first day of your last menstrual period? Date: If not, age period stopped: Do you use birth control? No If yes, what type? Gynecologic Problems No Endometriosis No Fibroids No Abnormal Pap smear No Other No Other Heavy vaginal discharge Heavy menstrual bleeding Hot Flashes Pain with sex Low sexual desire Pain/Cramping during Period Bleeding between Periods Other No Clinician Comments (for office use only) PREVENTIVE CARE IMMUNIZATIONS When was your last tetanus shot? / / No Do you have an annual flu vaccine? Date of last flu vaccine? / / No Have you had a pneumococcal vaccine (Pneumovax)? Date of last pneumococcal vaccine? / / No Have you had a shingles vaccine (Zostavax)? Date of last shingles vaccine? / / DIAGNOSTIC STUDIES Test Month/Year Comments Bone Densitometry Sigmoidoscopy or Colonoscopy Mammogram Pelvic Exam/Pap Smear PSA (Prostate Specific Antigen) LABORATORY AND IMAGING STUDIES NOTE: If you are not receiving health care through the UF/Shands Health Care system and you have copies of these reports at home, please bring them with you at the visit.
6 PERSONAL AND SOCIAL HISTORY 1. Where were you born and raised? 2. Describe your relationships with your parents and siblings: 3. How much education have you had? 4. Are you currently in a committed relationship? No If yes, for how long? Name of your spouse or partner: 5. On a scale of 1-10 with 1 being Strongly Dissatisfied and 10 being Strongly Satisfied, please rate how satisfied you are with this relationship: 6. Are you sexually active? No If yes, please rate how satisfied you are with your sexual life on a scale of 1-10 with 1 being Strongly Dissatisfied and 10 being Strongly Satisfied: 7. How many children do you have or have raised? Names and ages: 8. Who do you currently live with? Please include all people and pets: 9. Do you feel safe where you live? No 10. Are you a part of a community such as a church, volunteer/service organization? No If yes, please list: 11. Who are the most important people in your life at this time? 12. Do you have ongoing or past relationship issues/concerns? No 13. Which relationship(s) support or nourish you at this time? WORK HISTORY 1. Are you currently employed? No If yes, please describe your current job and your average number of hours of work per week: 2. On a scale of 1-10 with 1 being Strongly Dissatisfied and 10 being Strongly Satisfied, please rate how satisfied you are with your job at this time?
7 3. If you are not satisfied with your current work, what would you like to do instead? 4. Have you had other jobs/careers in the past? No If yes, please list: 5. If you re currently unemployed, please indicate the reason(s), and describe how you spend your daytime hours. 6. How would you describe your work life/home life balance at this time? 7. Has your health affected your ability to perform work optimally? No If yes, what do you want to improve? NUTRITION AND ENVIRONMENTAL/TOXIN EXPOSURE 1. What are your favorite foods? 2. What foods do you dislike or unwilling to eat? 3. What are your food cravings, if any? 4. Have you ever had an eating disorder? No If yes, please describe date of onset and treatment received: 5. Please describe what you typically eat each day: Breakfast: Lunch: Dinner: Snacks: Beverages: 6. Are you satisfied with your current eating habits? No If not, what do you want to improve? 7. Have you had any prolonged exposure recently or in the past to the following? No - Heavy metals (i.e. lead, mercury) No - Pesticides and herbicides No - Radiation No - Radon No - Molds 8. Do you consume organic food predominantly? No
8 9. What is your water source? 10. Do you currently smoke or use products containing nicotine? No If yes, how much (packs/day)? For how long? 11. Did you previously smoke or use nicotine? No If yes, for how long? When did you quit? 12. Do you consume alcohol? No If yes, how much? For how long? 13. Do you currently use illicit drugs? No If yes, which ones and how often? 14. Did you use illicit drugs in the past? No If yes, which ones and when did you quit? PHYSICAL ACTIVITY, FUNCTION AND REST 1. On a scale of 1-10 with 1 being Not Physically Active and 10 being Very Physically Active, please rate how physically active you are currently: 2. Describe your physical activity to include type of activity ( i.e. aerobic or strengthening exercises and recreational activities), frequency, and duration Physical Activity Frequency Duration 3. Are you satisfied with your level of physical activity? No If not, what limits this? What do you want to improve? 4. Has your health limited your ability to perform basic, daily activities? No If yes, please list which ones: 5. How many hours of sleep do you usually get at night? 6. Describe sleeping difficulties, if any (i.e. difficulty falling asleep, staying asleep, not feeling rested, restless sleeping)
9 EMOTIONAL AND MENTAL HEALTH 1. On a scale of 1-10 with 1 being No Emotional and Mental Stress and 10 being High level of Emotional and Mental Stress, please rate your emotional and mental stress at this time: 2. What are your main sources of stress at this time? No - Personal No - Work No - Home No - Other Please list 3. On a scale of 1-10 with 1 being Not effective at managing stress and 10 being Highly Effective at managing stress, please rate how well you manage stress in your life: 4. What specific practice/s do you use to cope with stress?(i.e. meditation, prayer, exercise, journaling, gardening) 5. What are your strengths? SPIRIT AND SOUL 1. What brings you joy? 2. What makes you laugh? 3. What helps you get through difficult times in your life? 4. What personal or professional accomplishments are you most proud of? 5. What are you most grateful for? 6. Do you have sense of purpose or meaning for your life? No If yes, what is this purpose or meaning? 7. Do you participate in activities that are part of a religious or spiritual community? No If yes, please describe. 8. On a scale of 1-10 with 1 being Plays No Role and 10 being Plays a Major Role, please rate how much influence your spirituality plays in how you take care of your health: 9. Would you like your health care provider to address spiritual issues with you? No If yes, how would you like us to address these? OTHER INFORMATION
10 Thank you for completing this form. We look forward to working with you to achieve optimal health and well- being!
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