Patient Information Form

Transcription

1 Patient Information Form Health Card # Version Code Expiry Date (If applicable) (If applicable) Last Name: First Name: Birth date: (Please write the exact name that is on your Health Card) Month / Day / Year Address: City: Postal Code Telephone: Business # ( ) Fax # ( ) Residence # ( ) Subscribe to our newsletter via: ( ) Postal Mail: ( ) (Please Check Appropriate Box) Occupation: Place of employment: Referred to clinic by: From what clinic: Family Physician: Address: Phone #: Fax # I consent to your office contacting my family doctor: YES NO I do consent to the diet program as explained to me: Signature * I have been made aware that there are no refunds for any discounted fees (2, 4 and 8 week packages) as set by Dr. Bernstein Diet & Health Clinics Signature FOR CLINIC USE ONLY Ontario RC: Checked by: If Health Card without a photo Check Photo ID ID Checked By: Date: British Columbia Eligibility: Photo ID Checked by: Alberta Photo ID Checked by: Staff Signature: Date:

2 HISTORY Patient's Name Age Date CHIEF COMPLAINT (reason for seeking Medical Advice) Present Illness (list symptoms, time of onset and duration) Past History: Please check if you have had any of the following: Birth defects or abnormalities Influenza Rheumatic Fever High Cholesterol (date) Measles Diphtheria Cancer High Blood Pressure (date) Mumps Polio Fibromyalgia Diabetes (date) German measles (3 day) Frequent Colds Chronic Fatigue Syndrome Gestational Diabetes Whooping Cough Tonsillitis Sleep Apnea Gall Bladder Stones (date) Chickenpox Pneumonia PMS Symptoms Thyroid Problems Scarlet Fever Unexplained Fever Menopausal Symptoms OTHERS Operations: (list with dates) Accidents: Current Medications (vitamins, birth control pills, supplements) Allergies to medicines, foods, etc. Nurse Signature Habits: How much of the following do you use: Alcohol Coffee Tobacco Water Soft Drinks Exercise: type Amount Hours of sleep each night Hours of work each day Social: Were you ever married? Years Separated Divorced Remarried Widow Family History: Father: Health Age Deceased at age Cause Mother: Health Age Deceased at age Cause No. of brothers No. living No. deceased Cause No. of sisters No. living No. deceased Cause Family Diseases: Check diseases known in your blood relatives (not yourself) High blood pressure Allergy Suicide Heart trouble Anemia Obesity Migraine Bleeding (abnormal) Arthritis Edema Epilepsy Rheumatic Fever Strokes Cancer Other Diabetes Nervous breakdown Kidney disease Syphilis or (bad blood) Examinations: Date of last physical examination Reason Hospitalizations Dates Reasons X-Rays: Chest Stomach Gallbladder Kidney Colon Others Electrocardiogram (heart tracing) Laboratory tests Date of last pap (cancer smear)

3 Please check if you have had any of the following conditions: General: SYSTEM REVIEW Patient Name: Weight loss lbs. Weight gain lbs. Usual weight lbs. Easily fatigues Weakness Lack of ambition Do you worry? About what? Do you generally feel well? Do you now have or have had any of the following? (Give dates if possible) Skin: Heart: Locomotor: Discoloration Heart trouble Joint pains Blemishes High blood pressure Muscle aches Rash Shortness of breath Arthritis: Rheumatoid ( ) Osteo ( ) Itching Lips or nails turn blue Limitation of motion Eczema No. of pillows slept on Deformity Hives Chest pain Backache Eyes: Palpitation or fluttering Leg pains Disease or injury Tire easily Varicose veins Poor vision Swelling of ankles Degenerative Disc Disease Wear glasses Coronary Stent Pain Nervous: Itching Nurse Signature Nervousness or anxiety Blurring Trouble sleeping Ears: Stomach / Bowels: Bored or depressed Infections, disease, injury Appetite - poor Nervous breakdown Decreased hearing Nausea or vomiting Headaches Noises Indigestion Fainting Discharge Abdominal pain Convulsions Throat / Mouth: Gas or bloating Loss of consciousness Frequent soreness Diarrhea Numbness Hoarseness Hard bowel movements Paralysis Difficulty swallowing Colitis Neuritis or Neuralgia Teeth abscessed No. of bowel movements - daily Nose: Change in bowel habits Menstrual History: Frequent bleeding Jaundice - skin yellow Menstruation began at age Stuffiness Hemorrhoids (piles) 28 day cycle? Postnasal drip Bleeding or black stools If no, how many days? Sneezing Hernia Duration of bleeding Sinus infections Pain with periods Hay fever Urinary System: Describe flow: Light ( ) Med. ( ) Heavy ( ) Chest and Lungs: Kidney disease 1st date of last menstrual period Lung disease Bladder disease Bleeding between periods Cough Kidney stones Bleeding after intercourse Raise sputum Urinary frequency Irritation or discharge Raise blood Painful urination Itching or burning Pleurisy Pus or blood in urine PMS symptoms Wheeze Albumen or sugar in urine Menopausal Symptoms Night sweats Dribbling of urine Asthma (on straining) Pregnancies: Emphysema Difficulty starting stream No. of pregnancies Bronchitis Stream small No. of miscarriages Sleep Apnea Urinate during night No. of live births Neck: Swelling or pain in genitals No. of children living Pain or stiffness Veneral disease No. of Caesarean operations Goiter Swelling, enlarged glands

4 SPECIAL WEIGHT HISTORY NAME DATE 1. When did you first become overweight? (your age then) (the year) 2. How did your weight gain start? Describe any circumstances: How many lbs. did you gain? How long did it take? Weight after gain 3. What do you think is the cause of your weight problem? 4. Your present weight: your weight goal: height: 5. What was your highest weight? your age then # of years ago (excluding pregnancy) 6. What was your lowest weight? your age then # of years ago (since childhood) 7. Have you ever stayed the same weight for 10 years or more? Yes: ( ) No: ( ) 8. Is your spouse heavy? 9. Are any family members heavy? (please list them) 10. Have you attempted to lose weight before? most lbs. lost: how long it took: 11. Describe previous methods of weight loss (diets, pills, injections, hypnosis, acupuncture, surgical intervention) and describe your results: 12. Do you have a history of eating disorder? If yes, please specify 13. Where and when do you do most of your overeating? 14. Please make any comments that you think might be helpful:

5 HEALTH APPRAISAL INDICATOR NAME DATE INSTRUCTIONS: Use the figures: (1) Mild, (2) Moderate, and (3) Severe to show degree of severity. Check only those symptoms which apply to your case; do not write "No" where answers do not apply. 1 Abnormal craving for sweets 2 Afternoon headaches 3 Alcohol consumption 4 Allergies - tendency to asthma, hay fever, skin rash, etc. 5 Awaken after few hours sleep - hard to get back to sleep 6 Aware of breathing heavily 7 Bad dreams 8 Bleeding Gums 9 Blurred Vision 10 Brown spots or bronzing of skin 11 Bruise easily "black and blue" spots 12 "Butterfly" stomach, cramps 13 Can't decide easily 14 Can't start in A.M. before coffee 15 Can't work under pressure 16 Chronic fatigue 17 Chronic nervous exhaustion 18 Convulsions 19 Crave candy or coffee in afternoons 20 Cries easily for no reason 21 Depressed 22 Dizziness 23 Drinks cups of coffee daily 24 Eat often or get hunger pains or faintness 25 Eat when nervous 26 Faintness if meals delayed 27 Fatigue, eating relieves 28 Fearful 29 Get "shaky" if hungry 30 Hallucinations 31 Hand tremor 32 Heart palpitates if meals missed or delayed 33 Highly emotional 34 Hunger between meals 35 Insomnia 36 Inward trembling 37 Irritable before meals 38 Lack energy 39 Magnifies insignificant events 40 Moods of depression "blues" or melancholy 41 Poor memory 42 Reduced initiative 43 Sleepy after meals 44 Sleepy during day 45 Weakness 46 Worrier, feel insecure 47 Do your symptoms come before breakfast? Answer "Yes" or "No" 48 Do you feel better after breakfast than before?