HEALING THE EYE & Wellness Centers Dr. Edward C. Kondrot, MD (H), CCH, DHt. J. Michael Pece, NMD Darrell Misak, ND, RPh
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1 HEALING THE EYE & Wellness Centers Dr. Edward C. Kondrot, MD (H), CCH, DHt. J. Michael Pece, NMD Darrell Misak, ND, RPh Phoenix, Arizona Pittsburgh, Pennsylvania HOMEOPATHIC EVALUATION QUESTIONAIRE Dear Patient, Please take your time and fill out this form. All this information is important and will be helpful in the selection of your homeopathic treatment. All your answers will be held in strict confidence. Edward C. Kondrot, MD TODAYS DATE NAME ADDRESS CITY/ STATE/ ZIP DAY & EVENING PHONE AGE SEX BIRTH DATE PLACE OF BIRTH PRESENT WT. & HT. MARITAL STATUS PROFESSION (OCCUPATION)
2 PRESENT COMPLAINTS. Please list each complaint and describe in detail (Use extra paper if necessary) ONSET ORIGIN OR CAUSE When did most of these complaints begin? Was there something which may have precipitated them, such as grief or shock? PAST HISTORY (PREVIOUS DISEASES AND TREATMENT) List details about your past medical history, including operations and injuries. MEDICATIONS List all of your medications that you are taking.
3 FAMILY HISTORY Give in detail if any of your relatives (note the relation to you) who are suffering or have suffered from the following : ALLERGIES Eczema Y N Skin allergy Y N Hay fever Y N Sinusitis or colds Y N Allergic bronchitis Y N Asthma Y N Urticaria Y N ARTHRITIS Gout Y N Osteoarthritis Y N Rheumatoid arthritis Y N OTHER MEDICAL CONDITIONS Cancer/Malignancy Y N Diabetes Mellitus Y N Hypertension Y N Coronary Heart Disease. Y N Tuberculosis (Pleurisy) Y N Gonorrhea/Syphilis or STD Y N Psychiatric A Mental Disorders Y N Schizophrenia Y N Anxiety Neurosis Depression Y N Any other sickness not mentioned above.
4 PERSONAL HISTORY: Kindly elaborate and mention habits like alcohol, smoking, drugs tobacco etc. APPETITE : Grade as per preference +, ++ or +++/ dislike or aversion -1, -2 or -3 Sweets What do you like? Salt and salty food (any extra salt) Sour things like pickles/ vinegar Seasoned and spicy Milk Eggs Fried foods and fat Foods that you like Foods that you dislike Any complaints after eating? for example: Fullness of abdomen Y N Gas formation Y N Diarrhea Y N Can you remain hungry for hours on end? Y N Does any item at food cause any discomfort e.g. acidity. headache, flatulence etc. Y N Do you feel bloated, full and heavy after eating Y N THIRST: Say and grade +, ++ or +++ How much water do you take at one time and how many times per day. Would you prefer cold/chilled water or drinks even in the height of winter? Warm/ hot in the height of summer? Iced cold drinks/ water Cold drinks Warm drinks Very hot
5 GENERALITIES State how you are affected by or how you react to the following : 1. Cold in general: cold air, drafts, cold winds etc. 2. Warmth in general: warmth of bed or of room, external warmth etc. 3. Weather: dry, cold, wet weather, rains, cloudy etc. 4. Thunder storms? 5. Open fresh air? 6. Sunlight and exposure to the sun? 7. Near the sea? Near the mountains? 8. Eating and drinking (before, during or after) any symptoms? 9. Fasting? 10. Any particular item of food /drinks which adversely affect you (or make you sick)? 11. Closed, crowded places (e.g.: elevators etc.)
6 12. Exertion or physical strain, mental strain? 13. Lack of sleep? 14. In what part of 24 hour day... Do you feel the best? Is there a specific time? Do you feel the worst? Is there a specific time? 15. Do your troubles tend to occur or become worse periodically? (e.g.; daily or alternate days, every week, yearly, during new or full moon etc.) STOOL/BOWEL MOVEMENTS - Do you regularly have a satisfactory bowel evacuations? - How many times do you move the bowels? When? - Consistency - Odor - Color of stool - Any straining for stools, even though they might not be hard or constipated? - Any urgency for stools (e.g. : do you have to run for bathroom first thing on waking up, in the morning or immediately after eating) - Any pain, burning. bleeding with stools? Piles/Fissure/Fistula? - Do you have flatus (wind) along with stools and is it noisy? URINE - Frequency, day and night; any smell (odor) in the urine? - Any difficulty in passage of urine? - Any difficulty in retaining urine? - Any associated complaints with urination?
7 SEXUAL SPHERE FOR MEN - Any sexual disturbance? - Excessive desire or aversion to sex? - Disability or performance, premature ejaculation etc. - Night emissions - Any H/O sexual abuse, excessive masturbation etc.? - Any problem or complaints after intercourse? FOR WOMEN - Age of appearance of first period (Menarche) - Pregnancies Children Abortions MENSES Periods - Regular or Irregular? (heavy, scanty, clotted, color odorous ) -Complaints associated with, before or after menses (e.g. headaches, irritability, premenstrual depression, diarrhea or constipation) -Any heaviness or pain in breasts before menses? -Any nodules in the breast, any other premenstrual symptoms? -Do you experience any sexual disturbances? -Desire/aversion to coitus? -Any leukorrheal (white discharge)? Itching, burning or discomfort? -Any sense of weight or bearing down at time of menses? MENOPAUSE Age of Any associated complaints at time at menopause, e.g.: Hot flashes, palpitation, anxiety, depression etc.? PERSPIRATION (SWEAT) 1. Do you perspire a lot?
8 2. Any particular part of the body, where you perspire more? 3. Any strong, offensive odor (e.g. sour etc.) associated with the sweat? 4. Does the perspiration stain the clothes? SLEEP 1. Do you sleep well? 2. Any particular posture in which you sleep, lying on the sides, back or on your abdomen etc.? 3. Do you feel refreshed after sleep? 4. Do you dream while sleeping? 5. Any particular dream that is recalled and often repeated (e.g. : frightening dreams, falling from a height, being pursued by someone, or dead people etc.) 6. Do any of your complaints get worse or better before, during, or after sleep? SKIN 1.Any skin problem that you have had earlier? (e.g.: allergies, eczema, fungal infections, pigmentation etc.)
9 2. Any itching or discoloration associated with it? 3. Any factors noticed which worsen the skin problem? 4. Any treatment taken for it? 5. Any complaint or abnormality of nails or the surrounding skin? 6. Any complaint of hair falling out, early graying, dandruff, thinning, etc.? 7. Any warts, moles, birth marks on the body? 8. Does skin heal normally or takes very long to heal? Any tendency to form excessive scar tissue? (Keloids)? Any tendency for wounds to suppurate (form pus easily)? THE MIND Have you noticed any marked changes in your mental state? If so describe in detail. Have you become or are you 1. Anxious/afraid of anything e.g.: being alone, animals, darkness, disease, thieves, robbers, sudden noises etc.?
10 2. Suspicious, doubting? 3. Impatient or hurried, hasty? 4. Offended easily (can't take any criticism)? 5. Are you overly critical of others, always finding fault? 6. Irritable, quarrelsome, violent etc.? 7. Depressed easily, sad or gloomy? 8. Timid/ shy, bashful? 9. Jealous or suspicious? 10. Anxious, restless, nervous or excitable? 11. Do you feel very anxious and apprehensive before examination, before stressful situations, public engagements etc.?
11 12. Are you silent, quiet, reserved or talkative? Make friends easily? 13. Are you very affectionate? Do you demand love and warmth from others? 14. Do you cry easily? What makes you cry (grief of others, music, kind words of affection etc.) 15. If someone consoles you when you are upset, does it help or does sympathizing with you makes matters worse? 16. Do you vent your worries, emotions etc., bottle them up inside you or brood over them? 17. How do you stand and react to contradiction? 18. Any imaginary fears or feelings? (e.g.: that someone might want to harm or hurt you or that people are against you) 19. How is your memory, power of concentration and mental ability? 20. Do you regret anything in life or resent certain people; if so who and for what reasons?
12 21. Do you feel humiliated or hurt easily? Would this give rise to any physical complaints? 22. Are you over conscientious about details., cleanliness, tidiness, punctuality, etc.? Are you a perfectionist by nature, being meticulous, fastidious and even finicky? 23. What is the greatest grief that you have felt in life? Also what are the greatest joys in life you have experienced? 24. Can you mentally relax easily; for instance, can you switch your mind off work, problems, children, etc.? Do you enjoy vacations? And can you totally relax when on a holiday or do thoughts of work or what is happening at home keeps bothering you, etc.? 25. At work or with colleagues, subordinates, or your boss or seniors: How do you equate with them? Would reprimand or scolding from them upset you tremendously? If so how? 26. How does music affect you? What type of music do you listen to?
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Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
HORMONAL LEVELS SELF TEST. Date Full Name No.
HORMONAL LEVELS SELF TEST Date Full Name No. This self-test to help your doctor if your levels of hormones are below normal. Circle the score for each line then total the score at the bottom of each hormone.
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
HOLISTIC HOMEOPATHY THERAPY
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Oriental Medicine Questionnaire
Oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Occupation: Height: Weight: Who referred you to this office? 1.What brought you
Name: Date of Birth: Age: Address: City State Zip
Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?
What do you feel are your child s strengths at this time?
PEDIATRIC MEDICAL QUESTIONNAIRE Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
Medical Questionnaire
MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of
2. Approx. Date of Onset: 3. Approx. Date of Onset:
Healthy Balance Lisa A. Dulac, L.Ac. Acupuncture Patient Intake Form Present Health Concerns: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: 2.
Minister Medical ^Acupuncture
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PERSONAL INFORMATION (Female intake form)
Brooke Phillips Diplomate of Oriental Medicine Natural Fertility Program 126 East Third Street, Suite A Rochester, Michigan 48307 (248) 841-1570 - brooke@rochesteracupuncture.us www.rochesteracupuncture.us
THE HORMONE HEALTH PROFILE
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Solanum malacoxylon rubrics (Jörg Hildebrandt 2010)
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STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit.
PATIENT HEALTH HISTORY FORM DIRECTIONS AND VISIT DAY INSTRUCTIONS Prior to your Appointment: STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit. STEP
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated
Wisdom Ways Acupuncture
Wisdom Ways Acupuncture 363 W. Drake Suite 1, Fort Collins, CO 80526 Phone (970) 227-3077 Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status:
Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :
New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit:
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
New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )
New Patient Intake Form Personal Information Name Date Address City State Zip Occupation Referred by I prefer to be contacted by: Phone ( ) Email Marital Status: Married Single Divorced Widowed Partnered