NATUROPATHIC CASE HISTORY DETAILS-

Transcription

1 NATUROPATHIC CASE HISTORY DETAILS- Name... DOB... /.../... Address... Phone No (Home)...(Mobile)...Work... address... Emergency Contact Name & Ph.... Doctor s Name & Address... Private Health Fund Name... Current Occupation/s-(include Paid & Unpaid work)... Hrs Per week...responsibilities/duties... Past Employment- How long? Type of Work. Chemical Exposure? Other?... What are your major stresses in life?... Relationship Status- married, de facto, divorced, single, separated- how long?... Children- No of own children, step children or other? Other children in your care?... Living/Family Situation- who do you live with, what is this like for you? Support?... Any family difficulties?... Education History & Qualifications/Current Studies-... Financial Responsibilities & strains (present & past)... Hobbies/... Exercise Routine... 1

2 PRESENTING COMPLAINTWhat is it that you are seeking treatment for? What symptoms are you currently experiencing? HEALTH HISTORY - Other current and Past Health Issues- Please list all the diagnosed medical conditions you have or have had in the past, including operations, no of births including miscarriages, acute and chromic conditions including any emotional or mental health issues: Is there anything else that troubles you in any other part of the body? CONDITION / ILLNESS HOW & WHEN DID IT START MEDICATIIONS / DETAILS Hospital visits/previous Operations/ Surgery/When Medical Tests/ Investigations requested/had in the past or recently Your Birth (Details of your own birth/adoption/).any significant events/accidents/trauma that occurred to you while in utero or to your mother during her pregnancy and giving or after birth that you know of What number child are you in the family?... Childhood Illnesses- Infectious Diseases- Serious Accidents/Traumatic Events eg grief, separation, car accidents, loss of family/friend, financial, emotional etc Overseas Travel & Illnesses 2

3 FAMILY HISTORY Illnesses in your family members Examples: Ca, BP problems, Diabetes, Stroke, Kidney Disease, Arthritis, Cardiovascular Disease, Mental Illnesses, Genetic Disorders- strong incidence or rare disorder etc Relative Health Conditions they have Died at Age / Cause of Death Your Mother Your Mother s Mother (Maternal Grandmother) Your Mother s Father (Maternal Grandfather Your Mother s Brothers/Sisters Your Father Your Father s Mother (Paternal Grandmother) Your Father s Father (Paternal Grandfather) Your Father s Brothers/Sisters Your own Brothers/Sisters Medications- What medications do you use, that have been prescribed for you? List below CURRENT MEDICATIONS OR NATURAL SUPPLEMENTS YOU ARE TAKING MEDICATION/SUPPLEMENT USED FOR DOSAGE PER DAY Are your meds being reviewed regularly by you doctor?... Compliance with medications. Is it difficult or easy to take medications as prescribed?... Do you find it easier to take tablets, powders or liquid medications?... 3

4 Adverse/Allergic Reactions- to anything/medications/food etc in the past Vaccinations Please list all vaccinations that you have had and any adverse reactions Chemical exposure-previous or Current Exposure to Toxic Chemicals/Pollutants/Paints Smoker- How many per day /week. How many years have you smoked? Alcohol What type, how much, how often? How much alcohol can you have? Recreational Drug Use- What & how often do you use? Past Use? Anything else you have used or taken in the past? Eg: Diet Pills, Energy supplements, vitamins etc Do you drink any of the following (Please Circle) Coffee, Black Tea,, Herbal Tea, Green Tea, Decaf How Many Cups per day?... Do you take milk in tea and coffee?... Sugar or Artificial Sweeteners in tea and coffee?... How many per cup?... Soft Drinks- How many per day?... Type ( diet, guarana, red bull etc)... Water Daily Intake... Alcohol None One per day Two per day Three to five per day More than 5 per day List the favourite foods that you like to treat yourself to What type of foods do you choose to eat for snacks between meals?... What times of the day are you most likely to snack or pick at foods?.. What types of foods do you like to have when you eat out or have take-away meals?..... How many meals per week would you eat that are not prepared in the home (inc bfast and lunches)? None 1-2 meals per week 2-5 meal per week 5-8 meals per week 8 or more per week Please list any food intolerance or food allergies? 4

5 YOUR TYPICAL DIET MEAL FOOD DRINKS Breakfast Mid Morning Snacks Lunch Afternoon Snack Dinner Late Night Snack Food l crave Foods l avoid 5

6 DO YOU OR HAVE YOU EXPERIENCED ANY OF THE FOLLOWING, PLEASE LIST HEAD- EG: Pain, Headaches, Migraines, Vision, Scalp, Hair, Other UPPER RESPIRATORY- Sinus, Ear, Nose, Throat, Glands, Cold, Flu, Mucus, Discharge, Pain LOWER RESPIRATORY Eg: Lungs, Breathing, Wheezing, Shortness of Breath, Coughing, Expectoration, Chest Pain, Pneumonia, TB, Fevers, Night Sweats, Chest X- Ray, Bleeding or discharge from breasts/lumps CARDIAC Blood Pressure, Heart Attack, Rheumatic Fever, Cold extremities, Numbness, Tingling, Shortness of Breath on exertion, or wakes you from sleep, Pain/Pressure in chest, neck, arms, Ankle swelling, Irregular or fast heart beat, Pain in legs with exercise UPPER DIGESTIVE Mouth, teeth, Stomach, Oesophagus, Liver, Burping, Reflux, Indigestion, Pain, Bloating, Difficulty Swallowing, Taste, tooth Decay, Appetite, Heartburn, Abdominal Pain, Cravings, Aversions, Thirst, No Thirst LOWER DIGESTIVE Bowels & Stools- Colour, Consistency, Shape, Size, Freq, Urge, Smell, Mucus, undigested Food, Blood, Constipation, Diarrhoea, Abdo pain, Anorectal pain, cramping, gas, bloating Hepatitis, Peptic ulcers, Colitis. How many motions per day? URINARY SYSTEM Colour, Pain, Frequent, Blood, Smell, Incontinence, Burning, Itching, Dribbling, Have to get up at night to urinate, Recurrent Urinary Infections, Rashes or lumps on genitals? 6

7 NERVOUS SYSTEM Concentration, Memory, Vertigo, dizziness, Fainting, Pain, Loss of Function, Numbness, Tingling, Gait, Blackouts, Hearing, Vision problems, Stroke, Brain Injury, Difficulty Sleeping MUSCULOSKELETAL Pain, Stiffness, Numbness, Tingling, ROM, Trauma, Spasm, Backache, Aching or swollen joints, Back or neck pain, Painful, blue or white fingers and toes with cold weather SKIN Scalp, dandruff, itching, burning, Dry, Oily, Allergies, Rashes, Moles, Psoriasis, Dermatitis, Eczema etc MALE REPRODUCITVE Sexual activity, libido, prostate, discharges, STD s Contraception Use, Operations, FEMALE REPRO Menarche Onset,, Cycle Length, Freq, Duration/Length of Bleed, Colour, Flow, Clots, PMT, Mid Cycle events, Pain, Symptoms during, before, after, OCP, IUD use, Discharge, Pregnancy, Miscarriages, Infertility, STD s, libido, level of activity, SLEEP Duration/ how long, Time they go to bed, time they go to sleep, refreshed or unrefreshed on waking, Dreams, Wakes time, What position in mot comfortable for you to sleep in? ENERGY None, some, plenty Always tired, score /10 THERMALS Hot, Cold, reactions to environment, what s too hot or too cold for you, What weather do you like and dislike? CRAVINGS AND AVERSIONS Foods you crave, eat often Foods you cannot tolerate PERSPIRATION Do you perspire easily, color, smell, where on the body do you sweat 7

8 MENTAL / EMOTIONAL Anxiety, Stress, Fear, Depression Grief, relationships with family, work, friends, coping mechanisms, reactions to environment, Stress Management techniques, Crying, Weeping, Motivation, Will, Drive, Desires, Goals in life, Habits, Prefer Company, Alone, or being alone Like Consolation- or not thoughts you experience and feel, worrying thought you have and how often LIKES AND DISLIKES What do other people like about you? What do you like about you? What attributes, attitudes and behaviours do you like in other people? What attributes, behaviours and attitudes do you not like in other people? What makes you angry/upset? 8