ew Jersey atural Medicine Dr. Jason Frigerio 4 Village Rd, ew Vernon, J 07976 p (973) 267-2650 f (973) 267-2659 Health History Form ame: Date: Address: City: State: Zip Code: Telephone (please check preferred contact number) # (home): (cell): E-mail address: Age: Date of Birth: Gender: female male Married: Separated: Divorced: Widowed: Single: artnership: Live with: Spouse artner arents Children Friends Alone Occupation: Hours per week: Retired: (Work address): How did you hear about our clinic? erson to reach in an emergency: Relationship: hone: What are your most important health problems? List as many as you can in order of importance: 1) 2) 3) 4)
(LEASE CIRCLE ES ASWERS OL) Childhood Illnesses Scarlet Fever Diphtheria Rheumatic fever Mumps Measles German Measles Hospitalizations and Surgery What hospitalizations or surgeries have you had? X-rays and Special Studies X-rays, CAT scans or other studies you have had: Electrocardiogram Immunizations olio ertussis Tetanus shot Dipthreia Measles/Mumps/Rubella Chikenpox Hepatitis Other: Are you hypersensitive or allergic to Allergies Any drugs? Any foods? Any environmental or chemical sensitivities? Current Medications Do you take or use? Laxatives ain relievers Antacids Cortisone Appetite suppressants Antibiotics Tranquilizers Thyroid medication Sleeping ills lease list any prescription medications, over the counter medications, vitamins or other supplements you are taking. 1) 5) 2) 6) 3) 7) 4) 8)
General Height: Weight: lbs. Weight 1 year ago: lbs. Maximum Weight: When: When during the day is your energy the best? worst? Typical Food Intake Breakfast: Lunch: Dinner: Snacks: To drink: Family History Do you have a family history of any of the following (please circle)? Cancer Diabetes Heart disease High blood pressure Kidney disease Epilepsy Arthritis Glaucoma Tuberculosis Stroke Anemia Mental Illness Asthma Hay fever Hives Any other relevant family history? = a condition you have now = a condition you never had = a condition you have had in the past Habits Main interests and hobbies? Do you exercise? If yes, what kind? Average 6-8 hrs. sleep Enjoy your work Awaken rested Take vacations Have a supportive relationship? Watch television Have a history of abuse how many hours? Any major traumas Read Use recreation drugs how many hours? Been treated for drug dependence Do you eat 3 meals a day Use alcoholic beverages Do you go on diets often Treated for alcoholism Do you eat out often Do you use tobacco Do you drink coffee Smoked previously Drink black/green tea How many years? Do you drink cola/soda How many packs per day? Do you eat refined sugar Do you add salt Do you have a religious or spiritual practice?
For the following, please circle = a condition you have now = a condition you never had = a condition you have had in the past Review of Systems Mental/Emotional Treated for emotional problems Depression Mood Swings Anxiety or nervousness Considered/attempted suicide Tension oor concentration Memory problems Immune Reactions to immunizations Reactions to vaccinations Chronic Fatigue Syndrome Chronic/Recurring infections Chronically swollen glands Slow wound healing Endocrine Hypothyroid Heat or cold intolerance Hypoglycemia Diabetes Excessive thirst Excessive Hunger Fatigue Seasonal depression eurologic Seizures aralysis Muscle weakness umbness or tingling Loss of memory Easily stressed Vertigo or dizziness Loss of balance Skin Rashes Eczema, Hives Acne, Boils Itching Color Change erpetual hair loss Lumps ight Sweats Head Headaches Head injury Migraines 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 ose and Sinuses Frequent colds ose bleeds Stuffiness Hay fever 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 eck Lumps Swollen glands Goiter ain or stiffness Respiratory Cough Sputum Spitting up blood Wheezing Asthma Bronchitis neumonia leurisy Emphysema Difficulty breathing Shortness of breath at night Shortness of breath Tuberculosis lying down Cardiovascular Heart disease Angina High/low blood pressure Murmurs Blood clots Fainting hlebitis alpitations/fluttering Rheumatic fever Chest pain Swelling in ankles Gastrointestinal Trouble swallowing Heartburn Change in thirst Abdominal pain or cramps Change in appetite Belching or passing gas ausea/vomiting Constipation Ulcer Diarrhea Jaundice(ellow Skin) Bowel movements: How often? Gall bladder disease Is this a change? Liver disease Black stools Hemorrhoids Blood in stool Urinary ain on urination Increased frequency Frequency at night Inability to hold urine Frequent infections Kidney stones Musculoskeletal Joint pain or stiffness Arthritis Broken bones Weakness Muscle spasm or cramps Sciatica Blood/eripheral Vascular Easy bleeding or bruising Anemia Deep leg pain Cold hands/feet Varicose veins Thrombophlebitis
Hernias Testicular ain Venereal disease Are you sexually active? Sexual orientation: Impotence Herpes Male Reproduction Testicular masses rostate Disease Discharge or sores Gonorrhea Chlamydia Genital warts Syphilis Female Reproduction / Breasts Age of first menses Date of last annual exam/a Age of last menses(if menopausal) Are cycles regular Length of cycle days Spotting between cycles Duration of menses days ain during intercourse ainful menses Clotting Heavy or excessive flow Discharge MS Birth Control If yes, what are your symptoms What type umber of pregnancies umber of live births umber of miscarriages Endometriosis umber of abortions Ovarian cysts Menopausal symptoms Difficulty conceiving Abnormal A Cervical Dysplasia Chlamydia Sexual Difficulties Genital warts Herpes Syphilis Are you sexually active Sexual orientation Do you do breast self exams Breast lumps Breast pain/tenderness ipple discharge