Arcana Center for Integrative Medicine

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Transcription:

Arcana Center for Integrative Medicine Patient s Name: Date of Birth: Reason for today s visit: Past Medical History Primary care physician: Date of last exam: (sick or well) Physician s Address: Office number: Allergies Are you/your child allergic to penicillin or any other drugs, food, or other substances? Yes No If Yes, please list: 1. Name of substance Reaction? 2. Name of substance Reaction? 3. Name of substance Reaction? 4. Name of substance Reaction? 5. Name of substance Reaction? Medications (prescription and other vitamins/supplements): 1. Name dose How many times a day 2. Name dose How many times a day 3. Name dose How many times a day 4. Name dose How many times a day 5. Name dose How many times a day Have you/your child ever been hospitalized? Yes No If yes, when, where and what for? 1. When Where What for 2. When Where What for 3. When Where What for

4. When Where What for 5. When Where What for Are you/your child being treated or have you/your child ever been treated for any of the following conditions? 〇 Sinus problems 〇 Seasonal allergies 〇 Eye problems 〇 Ear problems 〇 Heart disease 〇 Murmur 〇 High cholesterol 〇 High blood pressure 〇 COPD 〇 Asthma 〇 other lung problems 〇 Heartburn (reflux) 〇 Ulcers 〇 rectal bleeding 〇 Hepatitis 〇 Kidney problems 〇 Bladder problems 〇 Any Cancer 〇 Diabetes 〇 Thyroid problems 〇 Stroke 〇 Anemia or blood 〇 Seizures 〇 Arthritis 〇 Headaches 〇 Migraines 〇 Neurologic problems 〇 Neck pain 〇 Skin problems 〇 Depression 〇 Anxiety 〇 Back pain 〇 Psychiatric care

Please describe any current or past medical and dental treatment not listed above Please list any past surgeries (including dental work) and the date(s) you/your child had them Please list any sports and/or instruments you/your child has ever played (and the level) Please list any injuries, accidents or traumas you/your child has ever had Your/Your child s Birth History: (circle) Full-term Premature Late C-section Forceps/vacuum Vaginal delivery Any complications during the parent s pregnancy, delivery or post-partum (back pains, infections, etc)? Social and Preventive History Have you/your child ever used smoke/chew tobacco products, alcohol or marijuana Yes No If yes, explain which, how much and current use? Water intake per day: Sodas (# per week) Diet or regular? Dietary restrictions/preference:

Describe your/your child s sports, instruments, activities, exercise routine, or level of activity: Immunizations hx: Did you/your child receive all routine childhood vaccinations? Yes No If no, which shots were missed and why? Describe any difficulties you had or your child is having in school (ie. academic, social, emotional, physical, etc.) Gyn history: Number of pregnancies? Full term: # Pre-term: # Abortions/miscarriage # Symptoms of menopause/menopause? Yes or No Family History Living Age (or age at death) List serious illnesses Mother Living? Yes No If no, age/cause at death Father Living? Yes No If no, age/cause at death How many siblings do you have? Brothers Ages Sisters Ages Are your siblings living? If no, age at death Has any member of your/your child s family had any of the following illnesses: (List illness and which family member) Anemia or Blood disease Cancer Diabetes Heart disease High blood pressure Mental Illness / Depression Stroke Musculoskeletal disorders (osteoarthritis, rheumatoid arthritis ) Other serious illness REVIEW OF SYSTEMS Please mark any of the following symptoms that you/your child may currently have or within the last 3 months: 〇 Changes in appetite 〇 Fever / Chills 〇 Weight loss 〇 Weakness 〇 Blurred/Double vision 〇 Runny nose 〇 Sinusitis 〇 Nasal congestion

〇 Mouth breathing 〇 Problems with swallowing 〇 Sore throat 〇 Ear pain 〇 Shortness of breath 〇 Cough 〇 Wheezing 〇 Chest pain 〇 Palpitations 〇 Edema/swelling 〇 Abdominal pain 〇 Nausea 〇 Bloating/belching 〇 Flatulence 〇 Vomiting 〇 Diarrhea 〇 Constipation 〇 Heartburn 〇 Burning w/urination 〇 Frequent urination 〇 Urgency 〇 Loss of bladder control 〇 Weakness 〇 Numbness 〇 Problems with speech 〇 Memory problems 〇 Headaches 〇 Migraines 〇 Vertigo 〇 Dizziness 〇 Neck pain 〇 Shoulder pain 〇 Back pain 〇 Hip pain 〇 Knee pain 〇 Ankle/foot pain 〇 Elbow pain 〇 Wrist/hand pain 〇 Skin rash 〇 Behavior problems By signing below, I hereby certify that to the best of my knowledge all the information I have furnished on this form is complete, true and accurate. Patient/Legal Guardian Signature Date

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