Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX
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1 Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX FEMALE MEDICAL QUESTIONNAIRE (POSTMENOPAUSAL) NAME: DATE OF BIRTH: CHIEF COMPLAINT What is your primary problem? What kind of physicians have you seen for your health problem(s)? PAST MEDICAL HISTORY ILLNESS YEAR ILLNESS YEAR Y / N Cancer Y / N Irrit. Bowel Syndrome Y / N Chronic Fatigue Syndrome Y / N Kidney Disease Y / N Colitis Y / N Lupus Y / N Diabetes Y / N Mitral Valve Prolapse Y / N Elevated Cholesterol Y / N Mononucleosis Y / N Elevated Triglycerides Y / N Multiple Sclerosis Y / N Fibromyalgia Y / N Oral Yeast/Mouth Inf. Y / N Gall Bladder Disease Y / N Pelvic Inf. Disease Y / N Heart Disease Y / N Pneumonia Y / N Heart Attack Y / N Seizures Y / N HIV Positive Y / N Sex. Trans. Disease Y / N Hypertension Y / N Sleep Apnea Y / N Hyperthyroidism Y / N Stroke Y / N Hypothyroidism Y / N Tuberculosis 1
2 Y / N Hepatitis Y / N Ulcerative Colitis LIFETIME ANTIBIOTIC USE Approximately how many times have you used antibiotics over the past year? x Over the past 5 yrs? x/yr 10 yrs? x/yr 20 yrs? For what illness(es)? What year? How long did you take the antibiotics continuously? Was there any time in the past when you used antibiotics for 30 days or longer continuously for acne or illness? Y / N If for acne, did you take Accutane? Y / N For how long? HEADACHES REVIEW OF SYMPTOMS Y / N Do you have headaches? x/week x/month For how long? What do you take to relieve your headaches? NOSE Y / N Do you have colds, runny/stuffy nose, or sinus problems? How often? x/week x/month Y / N Do you snore? For how long? months years ASTHMA Y / N Did you ever have asthma or wheezing? How often? x/month x/year HEART Y / N Have you ever had a heart attack? When Y / N Do you ever feel your heart skip a beat? How often? Y / N Do you have chest pain? How often? How long does the pain last? How many years? The pain is: sharp / stabbing / dull / aching It radiate to your: neck / back / shoulders Y / N Do you feel like you are going to pass out? GASTROINTESTINAL SYSTEM Y / N Do you have: abdominal cramping / bloating / excessive belching / intestinal gas? How often? x/week For how long? 2
3 URINARY TRACT Y / N Have you ever had bladder infections/kidney infections? How many x/year? Y / N Have you ever had kidney stones? How many times? Year of last episode Y / N Do you have burning upon urination? Y / N Do you have increased frequency of urination? YEAST/SKIN FUNGUS Y / N Have you ever had a vaginal yeast infection? How many times? How many x/year? For how many years? SKIN Y / N Do you have any unexplained skin rashes or itchy skin? For how long? months years Do you know the cause of your rashes/itchy skin? Y / N Do you have dry skin? THYROID Y / N Have you been diagnosed with a thyroid disorder? Year diagnosed Y / N Were you diagnosed with hyperthyroidism (high)? Y / N Were you diagnosed with hypothyroidism (low)? Y / N Did you ever take thyroid medication? What year did you quit? Name of medicine MALAISE/FATIGUE Y / N Do you feel you should have more energy? What is your average energy level on a scale of 1-10 with 10 meaning brimming with energy and 1 meaning the inability to get out of bed? ENERGY LEVEL: /10 FLUID RETENTION Y / N Do you have swelling beneath your eyes or dark circles under your eyes? x/month Y / N Do you have swelling of your face, hands, or feet? x/month Y / N Is this swelling related to your periods? COLD SENSITIVITY 3
4 Y / N Do you have cold hands or feet? Y / N Are you sensitive to the cold or get chilled easily? SWEATING Y / N Do the palms of your hands or feet perspire unusually? Y / N Do you have decreased perspiration? HAIR CONDITION Y / N Do you have coarse or fine hair? Y / N Have you ever had significant hair loss? For how long? months years WEIGHT Y / N Have you had significant weight gain? How many pounds? pounds Since what year? Y / N Do you have difficulty losing weight? For how long? COGNITIVE ABILITY Y / N Do you ever feel that you have decreased mental sharpness? Y / N Do you have a poor short-term memory? For how many years have you had these problems? MOOD Y / N Do you ever feel discouraged, blue or depressed more than 10% of the time? What percent of the time? % Y / N Have you ever taken anti-depressants? Which one(s)? Between what ages? y.o. and y.o. BOWEL FUNCTION Y / N Do you have a bowel movement every day? How many times per week do you have a bowel movement? x/week Y / N Do you alternate between constipation and diarrhea? How many years? JOINT FUNCTION Y / N Do you have pain in any joint(s)? Circle which of the following joints: Neck Lower Back Elbows Wrists Finger joints Shoulder Hips Knees Ankles Toe Joints 4
5 How many times per week? MUSCLE Y / N Do you have muscle weakness? Y / N Do you ever have generalized muscle aches/cramping? Which muscles? Y / N Do you have any numbness or tingling in the extremities? Which ones? SLEEP Y / N Do you have insomnia or restless sleep? Y / N Do you feel tired after a full night s sleep? Y / N Do you have afternoon fatigue? How many hours of sleep do you require? hours/night? PREGNANCY Date of last normal menstrual period? / / At what age did you enter puberty? y.o. How many pregnancies? live births? miscarriages? Date of last child s birth Your age then? Y / N Did you have difficulty becoming pregnant? Y / N Did you ever receive infertility treatment? What kind? BIRTH CONTROL Y / N Have you had bilateral tubal ligation? If yes, when? / (mo/yr) Y / N Are you currently using an IUD? Y / N Have you ever taken Depo-Provera? Y / N Did you ever take birth control pills? If yes, for how long? mos yrs Date you discontinued BCP / Y / N Are you currently taking any female hormones (progesterone or estrogen)? If yes, which ones? For how long? PAP SMEAR Y / N Have you had an abnormal pap smear? If yes, when? / (mo/yr) Y / N Was your most recent pap smear normal? Date: / (mo/yr) HYSTERECTOMY Y / N Have you had a hysterectomy? Abdominal or Vaginal? What year? 5
6 For what purpose? Y / N Have your ovaries been removed? Right / Left What year? Y / N Did you take prescribed female hormones after your hysterectomy? What kind? For how many years? MENSTRUAL PERIODS Y / N Did your menstrual periods occur at the same time each month? If no, what was the shortest number of days between periods? What was the longest number of days between periods? How long were your menstrual cycles irregular? months years Y / N Were your menstrual cycles ever regular? How many days did your periods lasts? days Y / N Did you have bleeding that occurred between your normal periods? If yes, for how long did this occur? months years Y / N Prior to menopause were your periods heavier or lighter than in the past? If yes, when did they change? (mo/yr) How long? PREMENSTRUAL SYNDROME Y / N Did you have breast tenderness prior to your periods? If yes, how many days prior to your periods did it begin? days Y / N Do you have breast tenderness now? For how long? mos yrs Y / N Did you have mood swings prior to your periods? If yes, how many days prior to your periods did it begin? days Y / N Did you have fluid retention prior to your periods? For how many days prior to your period did it begin? days Y / N Did you have weight/gain prior to your periods? How many pounds did you gain prior to your periods? lbs Y / N Did you crave sweets, bread products, or salty foods prior to your periods? Y / N Did you develop headaches prior to your periods? If yes, how many days prior to your period did they begin? days Y / N Did you have menstrual cramps? If yes, for how many days? days Y / N Did any of the above symptoms ever cause you to miss work or school, or cause you to be unable to carry out your daily responsibilities? ESTROGEN DOMINANCE Y / N Do you have fibrocystic breast disease? For how long? mos yrs Y / N Do you have endometriosis? For how long? mos yrs Y / N Do you have uterine fibroids? For how long? mos yrs Y / N Do you have ovarian cysts? How many times? Which side? left right Y / N Have you developed dark hair on your face or breast? How long ago did it begin? mos yrs Y / N Do you have hot flashes? How many times per month? x/month Y / N Do you have night sweats? Y / N Have you had a decrease in your sexual desire? For how Long? 6
7 mos yrs Y / N Do you have painful intercourse? For how long? mos yrs Due to vaginal dryness? Y N BREAST Y / N Have you had a mammogram? How many? Date of last / Y / N Was your last mammogram normal? If no, then what were the findings? Y / N Have you had discharge from your breast? If yes, what color? For how long? mos yrs Y / N Have you had a breast biopsy? How many times? Y / N Have you had your breast(s) aspirated? How many times? Y / N Do you have breast implants? Saline / Silicon If yes, when was the surgery performed? / 7
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Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland
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Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
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Candida Questionnaire: Are your health problems yeast connected?
Candida Questionnaire: Are your health problems yeast connected? The following questionnaire can be given to your clients if you suspect candida is a problem. YES NO Have you taken repeated courses of
Section A: History. 1. Have you taken tetracyline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotic for acne for 1 month or longer?
CANDIDA QUESTIONNAIRE DR WENDY WELLS, NMD The total score will help you and your physician decide if your health problems are yeast-connected. ** Yeast-connected health problems are almost certainly present
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
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Nutrition Consultation Intake Form Please write or print clearly
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Essential Health Acupuncture Susana Byers, Lic..Ac. COMPREHENSIVE HEALTH HISTORY QUESTIONNAIRE
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My energy is lower than I would like it to. I feel exhausted after exercising or physical activity.
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Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
Ohio Northern University HealthWise. Authors: Alexis Dolin, Andrew Duska, Hannah Lamb, Eric Miller, Pharm D Candidates 2018 May 2018
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NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
Patient History Form
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The Rehabilitation Institute Cancer Rehabilitation
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Patient Information Name: Date of Birth: Age: (Last) (First) (M.I.) Height: Most Recent Weight: Home Address: City: State: Zip Code: Home Phone: Cell Phone: May we confirm appointments via text? YES NO
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