Medical History Form

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Transcription:

Medical History Form Full Name Title: Mr/Mrs/Ms/Miss Address Date of Birth Date Telephone: Mobile: Email: How did you hear about the Garden of health? G.P s Name and Address Are you currently seeing your Doctor? Why? List of Medication: List all past medical problems giving approx dates: List all past surgical procedures giving approx dates: Would you class the amount of antibiotics you have taken to date to be: Low Average High Are you seeing any other healthcare practitioners or therapists at the moment? Please list therapists and treatment:

Please list any nutritional, vitamin or mineral supplements you take: Please list any herbs or homeopathic remedies you take: Are you pregnant? Do you suffer from any of the following? High Blood Pressure Heart Problems Abdominal Hernia Haemorrhoids Renal Insufficiency Cirrhosis of the liver Do you have a pace maker? Do you have any implanted organs? Have you had an epileptic fit? Do you have a family history of any of the following and please state how sufferer is related to you: Heart Disease Cancer Diabetes Crohn s disease Ulcerative Colitis Any other condition which you feel may be relevant: Do you smoke? Yes/no How many do you smoke a day? Do you drink alcohol? How much in a week? Do you exercise? Yes/no If yes, what do you do and how often? How would you describe your lifestyle? Sedentary/Average/Active/Very Active

Do you drink tea and coffee? How much of each do you drink in a day? Do you drink water? How much do you drink in a day? Give an example of a typical days food for you: Please tick any of the following conditions that affect you now or have in the past Gastro-intestinal system Abdominal pain Crohn s Disease Rectal Itching Chronic Heartburn Indigestion Rectal Bleeding Constipation Haemorrhoids Mucous in Stools Diarrhoea Fissures/Fistulas Excessive Gas Colitis Vomiting of Blood Cancer Diverticulitis Diabetes Appendix Removed Abdominal Bloating Gall Bladder Disease Flatulence Liver trouble Ulcerative Colitis Burping How often do you have a bowel movement? What is the colour and consistency? Have you had any part of the colon removed? Any tests or investigations? Colonscopy Endoscopy Other Respiratory Shortness of breath Bronchitis Sinus Problems Chronic cough Asthma Emphysema Hay fever Pains or Tightness Skin Bruises easily Rash Psoriasis Dryness Acne Itching Eczema Dermatitis Fungal infections

Urinary Cystitis Prostate trouble Kidney infection Painful urination Kidney Stones Thrush Urgency to urinate Muscles and Joints Arthritis Neck pain Lower back pain Swollen joints Muscle Weakness Muscle paralysis Cardiovascular High Blood Pressure Angina Cold hands and feet Low Blood Pressure Poor circulation Rapid/irregular heartbeat Tingling Numbness in hands/feet Ears Deafness Itching Recurring infections Excessive wax Pain Fluid in ears Eyes Failing vision Double vision Watering Blurred vision Spots on vision Night blindness Mouth and Throat Bad breath Bleeding gums Blisters/ulcers Coated tongue Dry mouth Persistent cough Emotional/Nervous System Irritability Panic attacks Persistent headaches Inability to concentrate Fatigue Nervous exhaustion Mood swings Insomnia Depression Poor memory Lethargy Women Premenstrual tension Endometriosis Polycystic Ovaries Breast Pain Failure to menstruate Extremely heavy flow Vaginal discharge Menstrual cramping Too frequent periods Please give any other relevant information below: Name Signature Date

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