Dr. Jessica Kooima, PLLC 1830 South Alma School Road, Suite 112 Mesa, Arizona 85210 Phone: 480.730.6222 Fax: 480.889.5566 Date: Patient Name: Age: Date of Birth: Height: Weight: Gender: Marital Status: Married/Single/Divorced/Widowed Children: Occupation: Employer: Highest level of education: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship to Patient: Phone: How did you hear about us? Internet Search Website Referred by Practitioner? Who Current Patient? Who Other? Insurance Company: Primary Care Doctor: Pharmacy (if use specific pharmacy regularly) If patient is a minor, name of Parent/Guardian (s) Dr. Jessica Kooima, PLLC Page 1
HEALTH CONCERNS Please list your current health concerns in order from most bothersome to least bothersome. Please include mental, emotional, spiritual, and physical concerns: 1. 2. 3. 4. 5. 6. Hospitalizations/Surgeries/Major Illnesses Date Condition/Procedures 1. 2. 3. 4. 5. Xrays/Ultrasounds/CT Scans/MRIs/Other Imaging 1. 2. 3. 4. ALLERGIES Please list any medications, food, environmental or miscellaneous allergies: MEDICATIONS Please include prescription and over the counter: Medication Dosage/Frequency Condition Treated 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. SUPPLEMENTS Supplement/Brand Dosage/Frequency Condition Treated 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Dr. Jessica Kooima, PLLC Page 2
Family History Father, Mother, Child, Sibling, Maternal/Paternal Grandparents F M C S MG PG Alcoholism Allergies Alzheimer s Dz Anemia/Clotting Disorder Anxiety Disorder Arthritis Asthma Birth Defect Cancer: Cancer: Cancer: Depression Bipolar Diabetes Epilepsy/Seizures Gallbladder Dz Heart Attack High Cholesterol High Blood Pressure Hypoglycemia Kidney Dz Liver Dz Migraines Stroke Thyroid Dz Tuberculosis Other: Social History Exercise: Type/Frequency/Minutes Water intake: oz/day Coffee/Tea: oz/day Soda: oz/day Alcohol: oz/day/week/mos Cigarettes/Chewing pk/day yrs? Recreational Drug Use: What are your greatest sources of stress? What do you do to relieve stress? Do you have an active spiritual practice? Type: PAST MEDICAL CONDITIONS Please check any conditions in your history ADD/ADHD Chemical Dependency HIV Positive Prostate Problems AIDS Chicken Pox Kidney Disease Psoriasis/Eczema Alcoholism/Addiction Depression/Anxiety Leg Cramps Psychiatric Care Allergies Diabetes Liver Disease Rheumatic Fever Anemia Emphysema Lyme Disease Scarlet Fever Anorexia Epilepsy Measles Sexual Abuse Appendicitis Gall Bladder Disease Migraine Headaches Stroke Arthritis Glaucoma Miscarriage Suicide Attempt Asthma Goiter Mononucleosis Thyroid Condition Bipolar Gonorrhea Multiple Sclerosis Tonsillitis Bleeding Disorder Gout Mumps Tuberculosis Breast Lump Heart Disease Pacemaker Typhoid Fever Bronchitis Hernia Physical Abuse Ulcers Bulimia Herpes (Oral/Genital) Pneumonia Vaginal Infections Cancer: High Cholesterol Polio Venereal Disease Cataracts Mental/Emotional Abuse Physical Abuse Dr. Jessica Kooima, PLLC Page 3
VACCINATIONS: D=Disease, I=Immunized, N=Neither Measles: D I N Chicken Pox: D I N Mumps: D I N Hepatitis A: D I N Tetanus: D I N Pertussis/WC: D I N Flu: D I N Hepatitis B: D I N German Measles/Rubella: D I N Hepatitis C: D I N Vaccination Reactions: Review of Systems Present weight: lbs Weight one month ago: lbs Weight one year ago: lbs Height: feet in Ideal weight: lbs Good Energy: Fatigue: If you have fatigue, when in morning, afternoon, evening is it the worst If you have fatigue can you do what you need to during the day? Y N How many hours of sleep per night? What time go to bed? What time do you wake? If you wake up, what is the reason? Nightmares: Wake Refreshed: Must nap during the day: Sleep walk: Grind Teeth: Snore: SKIN Rash: Color Change: Hives: Lump: Psoriasis/eczema: Itchy: Dry: Warts/moles: Cancer of the skin: Perspiration: HEAD Headaches: Migraine: Dandruff: Head Injury: Oily Hair: Hair Loss: Dry Hair: EYES Dry: Blurry Vision: Watery: Cataracts: Double Vision: Styes: Glaucoma: Discharge: Strain: Dark Under Eyelid: Itchy: EARS Diminished Hearing: Ringing in Ears: Infections: Pain: Dr. Jessica Kooima, PLLC Page 4
NOSE Frequent Colds: Nosebleeds: Congestion: Post Nasal Drip: Polyps: Seasonal Allergies: MOUTH/THROAT Canker Sores: Cold Sore: Sore Throat: Gum Disease: Dentures: Cavities: Loss of taste: Hoarseness: NECK Stiffness: Swollen Glands: Full Movement: Tension: RESPIRATORY Cough: TB: Shortness of Breath: Bronchitis: W/ Exertion Pneumonia: Sitting Painful Breathing: Lying down Asthma: Wheezing: CARDIOVASCULAR High Blood Pressure: Rheumatic Fever: Low Blood Pressure: Murmurs: Arrhythmias: Palpitations: Edema: Chest Pain: URINARY TRACT Incontinence: Pain w/ urination: Frequent Infections: Kidney Stones: Urgency: Discharge/Blood: Dr. Jessica Kooima, PLLC Page 5
GASTROINTESTINAL Heartburn: Bowel Movement: (# of time per day) Indigestion: Recent BM Change: Bloating: Diarrhea/Constipation: Nausea: Hemorrhoids: Vomiting: Gall Bladder Disease: Change in Appetite: Liver Disease: Pancreatitis: Ulcer: MUSCULOSKELETAL Weakness: Arthritis: Stiffness: Leg Cramps: Tremors: Pain: NERVOUS SYSTEM Paralysis: Sciatica: Tingling/numbness: Carpal tunnel: Seizures: Fainting: MALE GENITALIA Testicular Pain/swelling: Sexually Active: Hernia: S.T.D.: Discharge: Prostate Disease Symptoms: Impotence: Sexual Orientation: FEMALE GENITALIA Age Period Began: How often period occurs: How long period lasts: Heavy menstrual bleeding: Menstrual cramping PMS: Menstrual Pain: Times Pregnant: Food cravings: Miscarriages: How many births: Abortions: Sexually Active: Dr. Jessica Kooima, PLLC Page 6
FEMALE GENITALIA (continued) Any abnormal paps: Use of hormones: Date: Type of hormones used: If menopausal since what age: Last Pap Smear: Dryness: Diagnosis: Pain w/ Intercourse: Healthy libido: S.T.D.: Vaginitis: Sexual Orientation: Mammography: Dexa Scan: If yes, what were the results: _ Please list any birth control used and ages used: Toxin Exposure Did you grow up near any refinery, polluted area or in a home with leaded paint? If so, what sort of pollution were you exposed to? Have you had any jobs where you were exposed to solvent, heavy metals, fumes or other toxic materials? Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing? Are you particularly sensitive to perfumes, gasoline or other vapors? Do you particularly use pesticides, herbicides or other chemicals around your home? If so, please list. Anything else I should know? Dr. Jessica Kooima, PLLC Page 7