Lisa Rosenberger, ND, LAc East West Integrative Health Clinic, LLC 217 Montowese St. Branford, CT 06405 203.915.9125 Name Date of First Visit Address City State Zip Code Telephone # (home) (work) (cell) Is it ok to leave a message? Age Date of Birth Social Security Number Gender Marital Status: Single Married Partnership Separated Divorced Widowed Live with: Spouse Partner Parents Children Friends Alone Roommates Occupation Hours per week Retired How did you hear about our clinic? Has any other family member already been a patient at the clinic? Emergency Contact Relationship Phone Address With in the past 24 months, please list the health practitioners you have seen for health care services: Practitioner Specialty Condition seeking treatment for Date # of visits Level of Satisfaction 1= very, 5= not at all Reason for Satisfaction or Dissatisfaction Were the above services covered by your insurance? YES NO 1
What are your most important health problems? List as many as you can in order of importance. 1) 2) 3) 4) 5) 6) GENERAL Weight lbs. Weight one year ago lbs. Max. Wt lbs. When? Height Any major Traumas? Family History Age (if living) Mother Father Brothers Sisters Maternal GM Maternal GF Paternal GM Paternal GF Health (G=good, P=poor) Age at death (if deceased) Cause of Death Check ( )those Applicable Cancer Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Mental Illness Asthma/Hayfever/Hives Allergies Eczema/Psoriasis Anemia Kidney Disease Glaucoma Tuberculosis Other Current Medications: Do you regularly take or use: (circle): Laxatives Pain Relievers Antacids Cortisone Appetite suppressants Antibiotics Tranquilizers Thyroid Medication Sleeping pills 2
Please list any prescription medications and over the counter medications you are taking, include dose and frequency: Please list any vitamin or other supplements you are taking: Allergies Are you hypersensitive or allergic to any of the following: Any drugs? Any Supplements?: Any foods? Any environmentals? Hospitalization and Surgery Have you had any hospitalizations or surgeries? YES NO If yes, for what condition? year: year: year: year: Typical Food Intake: Breakfast: Lunch: Dinner: Snacks: Beverages: Habits: Please list your main interests and hobbies: On average, how often do you exercise (circle): Never 1-2 times/ week 3-5 times/week >5 times/week Type of exercise: On average, how much sleep do you get each night? (circle) < 6 hours 6-8 hours >8 hours Do you sleep well? YES NO Do you awaken rested? YES NO Do you have a supportive relationship? YES NO Do you have a history of abuse? YES NO Do you drink alcoholic beverages? YES NO How many drinks weekly? 3
Do you use recreational drugs? YES NO Have you been treated for chemical dependence? YES NO Do you use tobacco? YES NO How much per day? Do you enjoy your work? YES NO Do you go on vacations? YES NO How often? Do you spend time outdoors? YES NO Do you watch television? YES NO If yes, how many hours/day? Do you read? YES NO If yes, how much? What do you enjoy most in your life? Do you have a religious/ spiritual practice? YES NO If yes, what type?: How does your illness affect you? How much change are you willing to make at this time for improving your health? (circle): Childhood Illnesses MINIMAL SOME COMPLETE For all of the following sections: Y = a condition you have now N = never had P = a condition you had previously Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles German Measles Immunizations Polio ertussis Y N Flu Y N Tetanus Y N Diphtheria Y N Chicken Pox Y N Measles/Mumps/Rubella Y N Hep B Y N H. Influnzae (HIB) Y N Musculoskeletal Joint pain or stiffness Broken bones Weakness Muscle spasms/cramps Arthritis Sciatica Blood/Peripheral Vasc. Easy bleeding/bruising Varicose veins Cold hands/feet Deep leg pain Anemia Thrombophlebitis Mental/Emotional Treated for emotional problems Considered/ Attempted Suicide Anxiety or Nervousness Mood swings Depression Memory problems Poor concentration Tension History of Abuse Y N Endocrine Hypothyroid Diabetes Heat/Cold intoler. Hyperthyroid Excessive thirst Weight loss/gain Hypoglycemia Fatigue Seasonal Depression 4
Immune Chronic Fatigue Synd. Chronic Infections Slow wound healing Chronic swollen glands Reactions to vaccinations Neurologic Seizures Paralysis Muscle weakness Numbness or Tingling Loss of memory Easily stressed Vertigo or dizziness Loss of balance Skin Rashes Acne, Boils Itching Itching Color Change Lumps Perpetual hair loss Night sweats Head Headaches Migraines Head Injury Jaw/TMJ problems Eyes Spots in Eyes Cataracts Impaired vision Glasses or contacts Blurriness Eye pain/strain Color blindness Tearing or dryness Double vision Glaucoma Ears Impaired hearing Ringing Earaches Dizziness Nose and Sinuses Frequent colds Nose bleeds Stuffiness Hayfever Sinus problems Loss of smell Mouth and Throat Frequent sore throat Copious saliva Teeth grinding Sore tongue/lips Gum problems Hoarseness Dental cavities Jaw clicks Neck Lumps Swollen glands Goiter Pain or stiffness Respiratory Cough Sputum Spitting up blood Wheezing Asthma Bronchitis Short of breath lying down Pleurisy Emphysema Difficulty breathing Pain on breathing Shortness of breath Short of breath at night Tuberculosis Pneumonia 5
Cardiovascular Heart disease Angina Murmurs High/Low blood pressure Blood clots Fainting Palpitations/fluttering Phlebitis Rheumatic fever Swelling in ankles Chest pain Gastrointestinal Trouble swallowing Heartburn Change in thirst Change in appetite Nausea Vomiting Vomiting blood Blood in stool Pain or cramps Belching or passing gas Constipation Diarrhea Gall bladder disease Black stools Ulcer Jaundice (yellow skin) Liver disease Hemorrhoids Bowel movements how often? Is this a change? Y N Urinary Pain on urination Incr. frequency Incontinence Frequency at night Frequent infections Kidney stones Condyloma (genit. warts) Chlamydia Gonorrhea Herpes Syphilis Male Reproduction Testicular masses Hernias Prostate disease Testicular pain Discharge Sores Premature ejaculation Impotence Are you sexually active? Y N Sexual orientation? Birth control type? Female Reprod./Breast Age of first menses Are cycles regular? Y N Length of cycle Age of last menses Duration of menses Clotting Bleeding between cycles Painful menses Discharge Heavy or excessive flow Light flow PMS PMS symptoms? Pain during intercourse Endometriosis Ovarian cysts Are you sexually active? Sexual orientation? Birth control What type? Number of pregnancies # of Live births # of miscarriages Number of abortions Abnormal PAP Breast self-exams? Breast pain/tenderness Breast lumps Nipple discharge Breast feeding Mastitis Menopause Menop. symptoms Welcome! We re happy to serve you. If you have any questions, please ask! 6