PERSONAL HEALTH INVENTORY
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1 Teresa McCurry, C.N.H.P. Passionate Health, 101 Old Mountain Rd., Powder Springs, GA Fax: PERSONAL HEALTH INVENTORY NAME DATE ADDRESS CITY, STATE, ZIP, COUNTRY HOME PHONE WORK PHONE CELL PHONE E MAIL ADDRESS OCCUPATION DATE OF BIRTH AGE HEIGHT WEIGHT ARE YOU PRESENTLY UNDER A PHYSICIAN S CARE? IF SO, LIST ALL CONDITIONS BEING TREATED: LIST ALL PRESCRIPTION AND OVER THE COUNTER MEDICATIONS YOU CURRENTLY TAKE: LIST ALL VITAMINS, HERBS OR OTHER SUPPLEMENTS YOU CURRENTLY TAKE: (If female) ARE YOU PREGNANT? HOW MANY MONTHS? Passionate Health Personal Health History Page 1 Revised 06/2008
2 HOW MANY BOWEL MOVEMENTS DO YOU HAVE? DAILY WEEKLY WHAT FORM OF EXERCISE DO YOU ENJOY? HOW OFTEN DO YOU EXERCISE (daily, 3 times a week, 2 a week, etc.) HOW LONG DO YOU EXERCISE IN ONE SESSION (15 min, 30 min, etc.) WHAT IS YOUR PRIMARY HEALTH CONCERN? PLEASE DESCRIBE IN DETAIL DESCRIBE YOUR DIET (vegan, vegetarian, high protein, high carbohydrate, south beach, raw foods, etc) PROVIDE SIGNIFICANT DETAILS OF YOUR DIET (many salads, frequent fried foods, daily protein shakes, skip certain meals, frequent juicing, meat 2 3 times per day, anything unique to you) HOW MANY 8 oz GLASSES OF WATER PER DAY? HOW MANY CUPS COFFEE OR REGULAR TEA PER DAY? HOW MANY GLASSES OF ALCOHOLIC BEVERAGES PER DAY? PER WEEK HOW MANY OUNCES OF SOFT DRINKS PER DAY? DIET OR REGULAR? WHICH OF THE FOLLOWING SWEETENERS DO YOU USE? WHITE SUGAR RAW SUGAR EQUAL SWEET N LOW SWEET THING STEVIA XYLITOL MAPLE SYRUP AGAVE SYRUP OTHER HOW MUCH INGESTED EACH DAY? Passionate Health Personal Health History Page 2 Revised 06/2008
3 HEALTH HISTORY: Have you ever been diagnosed with any of the following health problems? Tension Headaches Migraine headaches TMJ Disorder Back Pain or Sciatica Chest Pain or Angina Pain Rheumatoid Arthritis Osteoarthritis Lung or Respiratory Disorder Liver Disease or Hepatitis Urinary or Bladder Infection Kidney Disorder or Kidney Stones Gall Bladder Disorder or Gallstones Spleen or Lymphatic Disorder Gastric or Peptic Ulcer Irritable Bowel Syndrome or Colitis Diabetes Type I Diabetes Type 2 Onset Hypoglycemia Hyper Thyroid Hypo Thyroid Fibromyalgia Chronic Fatigue Syndrome Osteoporosis Tremors Peripheral Neuropathy Shingles (Herpes Zoster) Measles Mumps Chicken Pox Pneumonia Cancer Benign Tumors Blood Disorders Liver Disease Pancreatitis Glandular Disorders Coronary Disorder or Heart Attack Dysmenorrheal Reynaud s Disease Deafness or Tinnitus High Blood Pressure Low Blood Pressure Stroke Seizures or Epilepsy Concussion Cancer or Tumors HIV+ or AIDS Auto Immune Disorders High Cholesterol Venereal Disease Multiple Sclerosis Polio or Mononucleosis Allergies or Hay Fever Asthma or Bronchitis Tuberculosis Attention Deficit Disorder Obsessive Compulsive Disorder Panic Attacks or Phobias Clinical Depression Suicide Attempts Schizophrenia Pre menstrual Syndrome Prostate or Vaginal Disorder Anorexia or Bulimia Sexual Dysfunction Skin Disorder, Eczema, or Hives Other EXPLAIN ALL ITEMS CHECKED Passionate Health Personal Health History Page 3 Revised 06/2008
4 INJURIES: Have you ever been injured in any of the following types of accidents? List the specific injury and approximate date it occurred (month & year). AUTOMOBILE ACCIDENT SPECIFIC INJURY APPROX DATE SPORTS RELATED INJURY SPECIFIC INJURY APPROX DATE WORK RELATED INJURY SPECIFIC INJURY APPROX DATE SURGICAL COMPLICATION SPECIFIC INJURY APPROX DATE FALLS SPECIFIC INJURY APPROX DATE VICTIM OF CRIME OR ABUSE SPECIFIC INJURY APPROX DATE OTHER ACCIDENT OR INJURY SPECIFIC INJURY APPROX DATE EXPLAIN ALL CHECKED MAJOR SURGERIES AND APPROX YEAR: ALLERGIES AND TREATMENTS: Passionate Health Personal Health History Page 4 Revised 06/2008
5 CURRENT CONDITIONS: In the past year have you noticeably experienced any of the following? Pain in Legs or Feet Pain in Arms, Wrist, Hands Cold Hands or Cold Feet Swollen Ankles or Feet Stiff, Aching Joints Neck or Shoulder Tension Back Pain Grinding Your Teeth Rapid Heart Beat Irregular Heart Beat Abnormal Sweating Excessive Sweating Hyperventilation Dizziness or Fainting Large Weight Gain Large Weight Loss Overeating or Binge Eating Under Eating or Poor Appetite Craving for Sweets or Chocolate PMS Menopause Craving for Drugs or Alcohol Dissatisfaction With Job Bored or Uninterested in Things Loneliness or Lack of Nurturing Sex Life Not Satisfying Financial Worries Too Much Work Too Much Rest Too Much Fun Sinus Congestion Colds. Flu, Chills Sore Throats Nausea or Vomiting Diarrhea Less than 2 BM s per day Blurred /vision Lethargy, Fatigue Acid Reflux Heartburn/Indigestion Frequent Gas Laxative Use Difficulty Sleeping Disturbing Dreams Relationship Problems High Stress Level Emotional Abuse Physical Abuse Sexual Abuse Eye Problems Dental Problems Hearing Problems Other ADDITIONAL DETAILS RELEVANT TO ITEMS CHECKED ABOVE Passionate Health Personal Health History Page 5 Revised 06/2008
6 SUBSTANCES OR MEDICATION: In the past 6 months, have you regularly taken any of the following? Any Form of Tobacco 2 or More Cups Coffee per day Beer or Wine Liquor or Mixed Drink Aspirin or Tylenol Prescribed Pain Reliever Recreational Drugs 2 or More Glasses/Cans of Sodas per day 2 or More Glasses/Cups Tea per Day (do not include herbal tea) Sleeping Pills Anti Anxiety Pills Anti Depressants Blood Pressure Pills Insulin WHAT DO YOU CONSIDER TO BE YOUR GREATEST STRENGTH? WHAT DO YOU CONSIDER TO BE YOUR GREATEST WEAKNESS? WHAT IS YOUR SPIRITUAL OR RELIGIOUS ORIENTATION? (OPTIONAL) WHAT BUSINESS OR PERSON REFERRED YOU TO TERESA McCURRY? MAY I CONTACT THEM TO THANK THEM FOR THE REFERRAL? (List contact information below) After receiving your Credit/Debit Pre Authorization, your Coaching Agreement, and your 3 Questionnaires, Teresa will create a comprehensive Personal Health Blueprint for you which will provide the tools you need to achieve your health improvement objectives. It will also include a variety of resources and handouts to help you develop a healthy lifestyle to utilize for life! Passionate Health Personal Health History Page 6 Revised 06/2008
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PATIENT INFORMATION Please print clearly and complete all blanks
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PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
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
Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age
Health Profile ALTH PROFILE Dietary consultation involves a health profile which purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss
New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:
Pamela A. Pappas MD, MD(H) Classical Homeopathy for Mind, Body, and Soul 8114 E. Cactus Rd., Suite #240 Scottsdale, Arizona 85260 Phone: 480.656.9218 Fax: 602.626.3695 E-mail drpam@drpampappas.com New
Name (First Name and Last Initial ONLY) Date. Occupation. Education. Date of Birth Age Gender. How did you hear about AHE NYC World Student Clinic?
Name (First Name and Last Initial ONLY) Date Occupation Education Date of Birth Age Gender How did you hear about AHE NYC World Student Clinic? Family History Age If passed, cause of death Father Mother
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
Naturopathic Intake Form PERSONAL MEDICAL HISTORY
List any surgeries, hospitalizations, imaging (CT, MRI, EEG, EKG, etc.) Date MM/YY ALLERGIES Do you have any allergies to medications? [ ] Yes [ ] No If yes, list medication and reaction Do you have any