Gastrointestinal Heartburn / reflux / indigestion Blood or change in bowel movement Constipation Diarrhoea No problems
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1 Health Questionnaire General Information Name Address Date of Birth GP Name Tel Occupation Presenting Symptoms Postcode Mobile Surgery Number of children: Married Partner Single Divorced Widowed Other Reason for seeking treatment today: Please tick the box and/or circle any persistent symptoms you have had in the past few months. Read through every section and tick no problems if none of the symptoms apply to you. General Unexplained weight loss / gain Unexplained fatigue / weakness Poor appetite / eating disorders Fall asleep during day when sitting Fever, chills Skin New or change in mole Itching Eruptions / rash Allergic/Immune Hay fever / allergies Frequent infections Food sensitivities Hives Breast Breast lump / pain / nipple discharge Ears/Nose/Throat Nosebleeds, trouble swallowing Frequent sore throat, hoarseness Hearing loss / ringing in ears / ear pain Cardiovascular Chest pain / discomfort Palpitations (fast or irregular heartbeat) Respiratory Cough / wheeze Loud snoring / altered breathing during sleep Short of breath with exertion Gastrointestinal Heartburn / reflux / indigestion Blood or change in bowel movement Constipation Diarrhoea Genitourinary Leaking urine Blood in urine / pain urinating Night time urination or increased frequency Discharge: penis or vagina Concern with sexual function Musculoskeletal Neck pain Back pain Muscle / joint pain Endocrine Heat or cold sensitivity Unstable blood sugar Diminished sex drive Unwanted hair Hematologic/Lymphatic Swollen glands Easy bruising Neurological Headache Memory loss Fainting Dizziness Numbness / tingling Unsteady gait Frequent falls Eyes Change in vision / eye pain / redness Psychiatric Anxiety / stress / irritability Depression Hyperactivity Sleep problems / insomnia Nightmares Lack of concentration Poor memory Women only Pre-menstrual symptoms (bloating cramps, irritability) Problem with menstrual periods Hot flashes / night sweats
2 TIME-LINE Our life story provides useful information which can help direct a homeopath to the most relevant remedy for each individual. On looking at our biographical milestones in chronological order, patterns can emerge and sometimes a realisation that perhaps we have never been quite well since a certain event or experience. In order to explore this, please complete the form overleaf in brief, making sure to include: Major illnesses, including childhood diseases Accidents / injuries Hospital stays Medical treatments / surgical procedures / major dental work, including chemotherapy, radiotherapy and anaesthetics Onset of long term prescriptions, including antibiotics, contraceptives, steroids, blood pressure medication, HRT, anti-depressants, sedatives, etc. Excessive or prolonged drug use, prescribed or recreational Significant shocks, traumas or experiences, including anything which may have had an impact on your mental, emotional or physical well-being Problems experienced by your mother during pregnancy, physical or emotional Information about your birth, including pain relief and any other interventions If you are completing the form on behalf of a child, please fill in the details as if from their perspective.
3 TIME-LINE Stage Year Age Event & Comments (if needed) Pre-birth (Pregnancy) Birth >70
4 Please indicate if you or a relative have or have had any of the following conditions. Condition My Self Mum Dad Siblings Mum s mum Mum s Dad Dad s Mum Dad s Dad Other Relatives Comments ADD / ADHD Adrenal Disorders Alcohol / Drug abuse Allergy / Hay fever Alzheimer s Disease Anaemia Angina Anxiety Arthritis (Rheumatoid) Arthritis (Osteo) Asthma Bladder Problems Blood clot (leg) Blood clot (lung) Breast Lump (benign) Cancer Breast Cancer Colon Cancer Prostate Cancer Other Type Cataracts Colitis / Crohn s Disease Colon Polyp Coronary Artery Disease Croup Depression Diabetes (adult onset) Diabetes (juvenile onset) Diverticulitis Eczema Endometriosis Emphysema Epilepsy / Seizures Fibroids Fractures (broken bones) Gallbladder Disease Glandular Fever Glaucoma Gout Heart Attack Heart burn / Acid Reflux Hepatitis High Blood Pressure High Cholesterol Hip Fracture
5 Condition My Self Mum Dad Siblings Mum s mum Mum s Dad Dad s Mum Dad s Dad Other Relatives Comments HIV / Aids Irritable Bowel Syndrome Kidney Disease / Failure Kidney Stones Liver Disease Migraine Headaches Miscarriage Motor Neurone Disease Multiple Sclerosis Osteoporosis Parkinson s Disease Pneumonia Prostate Disorders Psoriasis Rheumatic Fever Chicken Pox / Shingles Sinus Conditions Sleep Apnoea Stomach Ulcers STD Stroke Thyroid Disorders Tuberculosis Whooping Cough Other: Childhood Conditions Disease Age Disease Age Chicken Pox Scarlet Fever Measles Tuberculosis Meningitis Whooping Cough Mumps Frequent Antibiotics Rubella Other Infant History Pregnancy Normal / Complications Delivery Normal / Forceps / Vacuum / Caes Breast Fed Y / N Birth Weight Crawled Early /Average / Late Walked Early /Average / Late Talked Early /Average / Late Immunisation History Vaccine Age Vaccine Age HBV / Hep B (Hepatitis B) PCV (Pneumococcal) MMR (Measles, Mumps, Rubella) OPV (Oral Polio Vaccine) DTP / DTaP (Diphtheria, Tetanus, Pertussis) HPV (Cervical Cancer) Varicella (Chicken Pox) Other: HbCV / Hib (H. Influenza type b conjugate) Please list any adverse reactions:
6 Medications Please include all current medications, supplements, herbs, homeopathic remedies, etc. Medicine Name Dose Who prescribed it? What do you take it for? Please list any medicines / supplements to which you are allergic: Lifestyle Smoking Alcohol Drug Use Exercise Diet Good Fair Poor Approximately how many cigarettes a day do / did you smoke? When did you start smoking? When did you quit? Approximately how many units of alcohol a week do / did you drink? Beer Wine Spirits Please list: What kind of exercise? How much per week? Please tick if you regularly eat / drink: Red Meat Poultry Fish Eggs Dairy Tofu Nuts Fruit Vegetables Pulses (Beans) Whole Grains Baked goods White Bread /Pasta /Rice Sweets Chocolate Fried food Water Tea Coffee Herbal Tea Fizzy drinks Please list any food intolerances / allergies: Terms and Conditions: I confirm that I have read the information on the Health Transitions website and that I understand and agree that Health Transitions offers an integrative and holistic approach to supporting health and encourages clients to seek independent medical advice and stay in close contact with their mainstream healthcare professionals. It is Health Transitions policy that should a client choose to withdraw from the use of prescribed medication while using holistic support, this should only be undertaken with the advice and supervision of their GP. Cancellation Policy: I confirm that I understand and agree that any failure to attend an appointment or cancellation after am on the previous working day (i.e. Friday for a Monday appointment) will require payment of the full consultation fee. Privacy: I confirm that I give consent for Health Transitions to store and use my personal information to analyse the conditions for which I have sought consultation, to prescribe remedies and other therapies and to communicate with me, where deemed appropriate, by or other digital methods, telephone or post. NAME: Date: Health Transitions periodically sends discounts and relevant information to existing clients. Please tick if you would like to be included. Signature: (Parent / Guardian if under 16 years)
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Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.
New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:
Spine New Patient Questionnaire Rev
Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please