ADULT MEDICAL QUESTIONNAIRE

Transcription

1 Mild Moderate Severe Good Fair Poor ADULT MEDICAL QUESTIONNAIRE HIRSCH HOLISTIC FAMILY MEDICINE 3525 Ensign Rd NE, Suite N Olympia, WA Ph: (360) Fax (Toll Free): Please return this packet no later than 48 hours prior to your appointment. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan. Patient s Full Name: Today s Date: Black or African American Hispanic or Latino Native Hawaiian / Pacific Islander Asian American Indian Alaskan Native Pacific Islander White Other HISTORY OF PRESENT ILLNESS What are the medical problems you would like addressed? Please rank in order of priority. SUCCESS Describe Current & Ongoing Problem Prior Treatment or Approach Example: Post Nasal Drip Elimination Diet In general, would you say your health is: Excellent Very Good Good Fair Poor Compared to one year ago, how would you rate your health in general now? Much better Somewhat better About the same Somewhat worse Much worse What do you hope to achieve in your visit with us? When was the last time you felt well? Did something trigger your change in health? What makes you feel worse? What makes you feel better? During the past 4 weeks, to what extent has your physical or emotional health interfered with your normal activities? t at all Slightly Moderately Quite a bit Extremely 1

2 How TRUE or FALSE is each of the following statements for you? Definitely True Mostly True Don t Know Mostly False Definitely False I seem to get sick a little easier than other people. I am as healthy as anybody I know I expect my health to get worse My health is excellent Childhood Yes No Don t Know Were you a full term baby? A preemie? Breast fed? Bottle fed? Was your birth spontaneous or induced? Caesarean-birth? Delivered in a US hospital? Where? Were you vaccinated as a child? As a child did you eat a lot of sugar and/or candy? Did you ever take abuse as a child? Did you feel safe as a child? Were you a sick or healthy child? Were you under a lot of stress as a child? Comment Where did you grow up? As a child, were there any foods that you had to avoid because they gave you symptoms? Yes If yes, please name the food and symptom (Example: milk gas and diarrhea): REVIEW OF SYSTEMS Please check if these symptoms occur presently or have occurred in the past 6 months. SKIN PROBLEMS Acne on Back / Chest / Face / Shoulders Athlete s Foot Bumps on Back of Upper Arms Cellulite Dark Circles Under Eyes Ears Get Red Easy Bruising Lack of Sweating Eczema Herpes-Genital Hives Jock Itch Lackluster Skin Moles w/ Color or Size Change Oily Skin Pale Skin Patchy Dullness Rash Red Face Sensitive to Bites Sensitive to Poison Ivy / Oak Shingles Skin Darkening Strong Body Odor Hair Loss Vitiligo ITCHING SKIN Skin in General Anus Arms Ear Canals Eyes Feet Hands Legs Nipples se Penis Roof of Mouth Scalp Throat SKIN, DRYNESS OF Skin in General Eyes Feet and Cracking? and Peeling? Hair and Unmanageable? Hands and Cracking? 2

3 and Peeling? Mouth / Throat Scalp and Dandruff? NAILS Bitten Brittle Curve Up Frayed Fungus-Fingers Fungus-Toes Pitting Ragged Cuticles Ridges Soft Thickening of: Finger Nails Toenails White Spots/Lines EARS Earaches, ear infections Drainage from ear Ringing in ears, hearing loss EYES Watery Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision HEAD Headaches Faintness Dizziness MOUTH / THROAT Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen/discolored tongue, gum, lips Canker sores RESPIRATORY Asthma, bronchitis Bad Breath Bad Odor in Nose Chest congestion Cough-Chronic Cough-Dry Cough-Productive Difficulty breathing Excessive mucus formation Hoarseness Sore Throat Hay Fever: Spring Summer Fall Winter Nasal Stuffiness se Bleeds Post Nasal Drip Sinus Fullness Sinus Infection Shortness of breath Sneezing attacks Snoring Wheezing Winter Stuffiness LYMPH NODES Enlarged/neck Tender/neck Other Enlarged/Tender CARDIOVASCULAR Angina / Chest Pain Breathlessness Heart Murmur Irregular Pulse Palpitations Phlebitis Swollen Ankles / Feet Varicose Veins URINARY Bed Wetting Hesitancy (trouble getting started) Infection Kidney Disease Leaking / Incontinence Pain / Burning Urinary Infection Urgency DIGESTIVE TRACT Nausea or vomiting Diarrhea Constipation Bloated feeling Belching, or passing gas Heartburn Intestinal / Stomach pain JOINTS / MUSCLES Pains or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness WEIGHT Binge eating / drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight ENERGY / ACTIVITY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness EMOTIONS Mood swings Anxiety, fear, or nervousness Anger, irritability, or aggressiveness Depression MIND Poor Memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities MALE REPRODUCTIVE Discharge from Penis Ejaculation Problem Genital Pain Impotence Prostate Infection Lumps in Testicles Poor Libido (Sex Drive) FEMALE REPRODUCTIVE Breast Cysts Breast Lumps Breast Tenderness Ovarian Cyst Poor Libido (Sex Drive) Vaginal Discharge Vaginal Odor Vaginal Itch Vaginal Pain with Sex Premenstrual: Bloating Breast Tenderness Carbohydrate Cravings Chocolate Cravings Constipation Decreased Sleep Diarrhea Fatigue Increased Sleep Irritability Menstrual: Cramps Heavy Periods Irregular Periods Periods Scanty Periods Spotting Between 3

4 PERSONAL MEDICAL HISTORY Date of last full physical exam: Provider: Please list past and current medical conditions / diagnoses received: ILLNESSES AND DIAGNOSES WHEN COMMENTS INJURIES WHEN COMMENTS DIAGNOSTIC STUDIES (CT, EKG, etc.) WHEN COMMENTS OPERATIONS WHEN COMMENTS HOSPITALIZATIONS WHERE/WHEN REASON PREVENTIVE TESTS (DEXA scan, ultrasound, mammogram, etc.) WHEN REASON BLOOD TYPE A B AB O Rh+ Unknown 4

5 WOMEN S HISTORY (for women only): Have you ever been pregnant? Yes Number of miscarriages Number of abortions Number of preemies Number of term births Birth weight of largest baby and of smallest baby Did you develop toxemia (high blood pressure)? Yes Have you had other problems with pregnancy? Yes If so, please comment: Age at first period Date of last Pap Smear Date of last Mammogram Pap Smear: rmal Abnormal Mammogram: rmal Abnormal Have you ever used birth control pills? Yes If yes, when Are you taking the pill now? Yes Did taking the pill agree with you? Yes t applicable Do you currently use contraception? Yes If yes, what type of contraception do you use? Are you in menopause? Yes If yes, age at last period Do you take: Estrogen? Ogen? Estrace? Premarin? Other (specify) Progesterone? Provera? Other (specify) How long have you been on hormone replacement therapy (if applicable)? In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)? Yes t applicable MEN S HISTORY (for men only): Have you had a PSA done? Yes PSA Level: Prostate Enlargement Prostate Infection Change in Libido Impotence Difficulty Obtaining an Erection Difficulty Maintaining an Erection cturia (urination at night) How many times at night? Urgency/Hesitancy/Change in Urinary Stream Loss of Control of Urine 5

6 SOCIAL TRAVEL Have you lived or traveled outside of the United States? Yes If so, when and where? DENTAL Have you ever had dental surgery? Yes When? What kind? Do you have mercury amalgam fillings? Yes How many? For how long? ANTIBIOTICS & STEROIDS How often have you have taken antibiotics? Less than 5x More than 5x Infancy/ Childhood Teen Adulthood How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)? Less than 5x More than 5x Infancy/ Childhood Teen Adulthood RECREATIONAL DRUGS Are you currently using any recreational drugs? Yes Type: Have you ever used IV or inhaled recreational drugs? Yes TOBACCO Have you ever used tobacco? Yes If yes, number of years as a nicotine user: Amount per day: Year quit: If yes, what type of nicotine have you used? Cigarette Smokeless Patch/Gum Cigar Pipe e-cigarette Are you (or were you) exposed to second hand smoke regularly? Yes ALCOHOL Have you ever used alcohol? Yes If yes, how often do you now drink alcohol? Drinks per Day Week Month Year If yes, please also answer the following: Yes No Have you ever been told you should cut down your alcohol intake? 6

7 Yes No Do you get annoyed when people ask you about your drinking? Do you ever feel guilty about consumption of alcohol? Do you ever take an eye-opener? (an alcoholic drink first thing in the morning) Do you notice a tolerance to alcohol (can you hold more than others)? Have you ever been unable to remember a drinking episode? Do you get into arguments or physical fights when you have been drinking? Have you ever been arrested or hospitalized because of your drinking? Have you ever thought about getting help to control or stop your drinking? CAFFEINE Caffeine intake: Yes Cups/day: Coffee Tea Other: Do you have an adverse reaction to caffeine? Yes When you drink caffeine do you feel: Irritable or Wired? If yes, what reaction? Aches & Pains? WATER How much water do you drink per day? EXERCISE Do you exercise regularly? Yes If so, how many times a week? When you exercise, how long is each session? 1x 15 min or less 2x min 3x min 4x or more More than 45 min What type of exercise is it? Flexibility and Range of Motion Strengthening and Resistance Cardiovascular and Aerobic Yoga Curl-ups (Sit-ups) Jogging Tai Chi Push-ups Walking Stretching Weight Training Aerobics Other (Specify): Other (Specify): Swimming Other (Specify) Is playing sports a part of your regular exercise? Yes If so, which sport(s)? LOSS Have you experienced any major losses in life? Yes If so, please comment: 7

8 STRESS Have you or your family recently experienced any major life changes? Yes If yes, please comment: Are you happy? Yes Do you feel your life has meaning and purpose? Yes Do you believe stress is presently reducing the quality of your life? Do you feel you have an excessive amount of stress in your life? Do you feel you can easily handle the stress in your life? Yes Yes Yes Daily Stressors (Rate the intensity of each on a scale of 1-10, with 10 being the most stressful) Work: Family: Social: Finance: Health: Other: COPING STRATEGIES Do you practice meditation or a relaxation technique? Yes How often? Check all that apply: Yoga Meditation Imagery Breathing Tai Chi Prayer Other Have you ever had psychotherapy or counseling? Yes Currently? Previously? If previously, from to. What kind of therapy? Provider? Comments: SLEEP Average number of hours you sleep per night: less than 6 Do you have trouble falling asleep? Yes Sometimes Do you feel rested upon awakening? Yes Sometimes Do you have problems with insomnia? Yes Sometimes Do you snore? Yes Sometimes Do you ever use sleeping aids? Yes Explain: Do you have morning headaches? Yes Sometimes Do you wake up during the night? Yes Sometimes How many times per night? To urinate? Yes Other reason? 8

9 RELATIONSHIPS With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister Are you currently, or have you ever been, married or in a long-term relationship? Yes If so, when did your relationship begin? Spouse/Partner occupation: Have you separated? Yes If so, when? Have you divorced? Yes If so, when? Have you had any other previous marriages/long-term relationships? Yes Comments: Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes. Please do your best to answer the following questions: Have you been involved in abusive relationships in your life? Yes Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? Yes Do you currently feel safe in your home? Yes Do you feel safe, respected and valued in your current relationships? Yes Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? Yes Would you feel safer discussing any of these issues face-to-face instead of on paper? Yes SEXUAL Do you believe that your sexual activity is appropriate for you during this stage of your life? Do you have any challenges having sex? (e.g. pain, performance, or intimacy issues) 9

10 ENVIRONMENTAL TOXINS Do you feel worse at certain times of the year? Yes If yes, when? Spring Fall Summer Winter Have you, to your knowledge, been exposed to toxic metals in your job or at home? Yes Do odors affect you? Yes Do you adversely react to (check all that apply): Monosodium glutamate (MSG) Bananas Caffeine Aspartame (Nutrasweet) Garlic Onions Cheese Citrus Preservatives (ex. sodium benzoate) Alcohol Red wine Other: Sulfite containing foods (wine, dried fruit, salad bars) Which of these significantly affects you? (check all that apply): Cigarette Smoke Perfumes/Colognes Auto exhaust fumes Other: In your work or home environment, are you exposed (or have you been exposed) to: Chemicals Electromagnetic Radiation Mold If chemicals, which one(s)? Lead Arsenic Aluminum Have you ever turned yellow (jaundiced)? Yes Cadmium Mercury Have you ever been told you have Gilbert s syndrome or a liver disorder? Yes Explain: Do you have a known history of significant exposure to any harmful chemicals such as the following: Herbicides Insecticides (frequent visits of exterminator) Pesticides Organic Solvents Heavy metals Other Chemical name(s), date(s), length of exposure: Do you dry clean your clothes frequently? Yes Do you or have you lived or worked in a damp or moldy environment or had other mold exposures? Yes Have you ever had any water damage (ex. broken pipe or flooding) in your house? Yes When? Has your house ever been tested for mold? Yes Do you ever come home and your house smells musty? Yes Do you have any pets or farm animals? Yes If yes, where do they live? Indoors Outdoors Do you have carpeting? Yes A wood stove? Yes Wood Paneling? Yes 10

11 SPIRITUAL How important is religion (or spirituality) for you and your family s life? t at all important Somewhat important Extremely important How do you connect with spirit? Do you believe in God? WORK Current occupation: Do you like the work you do? Do you spend the majority of your time and money fulfilling responsibilities and obligations? Yes How much time have you lost from work or school in the past year? 0-2 days 3 14 days More than 15 days Previous jobs: PLAY What do you do for fun? Hobbies and leisure activities: What is your bliss or joy? DIET Are you on a special diet? Yes Ovo-lacto Vegetarian Gluten Free/Dairy Free Diabetic Vegan Paleo Dairy-restricted Blood type diet Other (describe): Is there anything special about your diet that we should know? Yes If yes, please explain: Do you currently have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? Yes If yes, are these symptoms associated with any particular food or supplement(s)? Yes Please name the food or supplement and symptom(s). (Example: milk gas and diarrhea.) Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes 11

12 Do you feel much worse when you eat a lot of : High fat foods High protein foods High carbohydrate foods (Breads, pastas, potatoes) Refined sugar (junk food) Fried foods 1 or 2 alcoholic drinks Other Do you feel much better when you eat a lot of : High fat foods High protein foods High carbohydrate foods (Breads, pastas, potatoes) Refined sugar (junk food) Fried foods 1 or 2 alcoholic drinks Other Does skipping a meal greatly affect your symptoms? Yes Have you ever had a food that you craved or really "binged" on over a period of time? Yes Food craving may be an indicator that you may be allergic to that food. If yes, what food(s)? Do you have an aversion to certain foods? Yes If yes, what foods? BOWEL MOVEMENTS Please fill in the chart below with information about your bowel movements: Frequency Color Consistency More than 3x/day Medium brown consistently Soft and well formed 1-3x/day Very dark or black Often float 4-6x/week Greenish color Difficult to pass 2-3x/week Blood is visible. Diarrhea 1 or fewer x/week Varies a lot. Thin, long or narrow Dark brown consistently Small and hard Yellow, light brown Loose but not watery Greasy, shiny appearance Alternating between hard and loose/watery Intestinal gas: Daily Present with pain Occasionally Foul smelling Excessive Little odor 12

13 MOTIVATION Rate on a scale of 5 (very willing) to 1 (not willing) In order to improve your health, how willing are you to: Comments: Significantly modify your diet Take several nutritional supplements each day Keep a record of everything you eat each day Modify your lifestyle (e.g., work demands, sleep habits) Practice a relaxation technique Engage in regular exercise Have periodic lab tests to assess your progress FAMILY HISTORY Please indicate only blood relatives. Mother Current Age (or age at death, if deceased) Good health currently? Known Health Issues Father Brothers Sisters Children Grandmothers Grandfathers Uncles & Aunts Other 13

14 ALLERGIES Are you allergic to any medications or supplements? Yes If yes, please list: Are you allergic to any foods? Yes If yes, please list: MEDICATIONS What medications are you taking now? Include non-prescription drugs. Medication Name Date started Dose/Frequency Reason for Use SUPPLEMENTS List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible. Vitamin/Mineral/Supplement Name Date started Dose/Frequency Reason for Use 14

15 3-DAY DIET DIARY INSTRUCTIONS It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day. Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits. Record information as soon as possible after the food has been consumed Describe the food or beverage as accurately as possible e.g., milk what kind? (whole, 2%, nonfat); toast (whole wheat, white, buttered); chicken (fried, baked, breaded), coffee (decaffeinated with sugar and half-n-half). Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, ½ cup, 1 teaspoon, etc. Include any added items. For example: tea with 1 teaspoon honey; potato with 2 teaspoons butter, etc. Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc. Include any additional comments about your eating habits on this form (ex. craving sweets, skipped meals and why, when the meal was at a restaurant, etc). Please note all bowel movements and their consistency (regular, loose, firm, etc.) DIET DIARY DAY 1 TIME FOOD / BEVERAGE / AMOUNT COMMENTS Bowel Movements (#, form, color) Stress/Mood/Emotions 15

16 DAY 2 TIME FOOD / BEVERAGE / AMOUNT COMMENTS Bowel Movements (#, form, color) Stress/Mood/Emotions DAY 3 TIME FOOD / BEVERAGE / AMOUNT COMMENTS Bowel Movements (#, form, color) Stress/Mood/Emotions Please return this packet no later than 48 hours prior to your appointment. 16