Adult Health History Summary

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Transcription:

Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear about our clinic? Family Medical Doctor Contact Current Health Concerns What is your main reason for coming in today? Please include how long you have had this concern, whether it is getting better, worse or unchanged, and any treatments you have tried. List in order of importance your health concerns: 1) date of onset 2) date of onset 3) date of onset 4) date of onset Other concerns: Have you ever seen a naturopathic doctor, chiropractor, acupuncturist or other natural health practitioner ( Y / N )? If yes, who did you see? pg. 1

Your Health History The general state of your health is (please check): Excellent Good Average Fair Poor Please list the 5 most significant stressful events or ongoing stressors in your life: 1) date (if applicable) 2) date (if applicable) 3) date (if applicable) 4) date (if applicable) 5) date (if applicable) Please indicate any of the following that you have had or currently have with an N (now) or a P (past): Asthma Allergies Alcoholism Anemia Arthritis Blood Pressure Abnormalities Bronchitis Cancer Chronic Fatigue Carpal Tunnel Syndrome Circulatory Problems Colitis Dental Problems Depression Diabetes Drug Addiction Eating Disorder Epilepsy Emphysema Eye/Ear/Nose Problems Environmental Sensitivities Insomnia Food intolerance Gout Heart Disease Chronic Infection Irritable bowel syndrome Kidney/bladder disease Learning disabilities Mental Illness Liver Disease Gallstones Migraine headaches Sinus problems Stroke Thyroid trouble Obesity Pneumonia Sexually transmitted disease Skin problems Tuberculosis Ulcer Urinary tract infection Varicose Veins Heart Burn Fibromyalgia Glaucoma Other pg. 2

Please list current medications: Please list current supplements including the dose (this includes homeopathics, vitamins, minerals, tinctures): Do you have any allergies? (ie drug, food, plants, animals, etc) Did you receive the full childhood vaccination schedule? Any recent vaccinations? Have you had any of the following childhood illnesses (please check applicable): Measles Mumps Chickenpox Whooping Cough Polio Mononucleosis Diptheria Rheumatic Fever Scarlet Fever Other Which (if any) of the following do you currently use? Provide approximate frequency if applicable (ie. sometimes, often, seldom) Alcohol Tobacco Hormones Cortisone Sedatives Coffee Laxatives Antacids Recreational Drugs pg. 3

Family History Do you have any blood relatives (parents, siblings, grandparents) who have or have had any of the following conditions? Please fill out to the best of your knowledge, no need to ask family members. Check yes and provide more information if applicable. Allergies Arthritis Asthma Cancer Diabetes Anemia Depression Skin Disease Heart Disease Genetic Disorder (including mother, father, grandparents, siblings) Blood Pressure Abnormalities Stroke Ulcers Cataracts Thyroid Problems Hypoglycemia Seizures Sickle Cells Mental illness Any other significant family health history Personal Habits/Lifestyle What do you enjoy most in your life? What are your main interests or hobbies? What do you worry most about? Do you have a spiritual practice? Do you exercise? If yes, what type and frequency? Do you have any sleep problems? How many hours of sleep would you say you get per night, on average? Do you wake feeling refreshed? Do you awaken through the night? Do you sweat at night? How many hours of sleep do you think you need? Do you enjoy your work? Do you take vacations? Are you in a happy and supportive relationship? How often do you get colds, flus, and sore throats? How much water do you drink per day (on average)? Any environmental allergens or exposures to on a regular basis we should be aware of? pg. 4

Digestion Do you have any problems with gas, bloating or excessive fullness? If so, how long have you had this? How often do you have a bowel movement? Do you ever have any blood, mucus, or undigested foods in your stool? Do you ever have any problems with constipation? Diarrhea? Do you ever have heartburn? Do you have disagreeable breath? Have you travelled outside of Canada in the last 5 years? Have you ever had a parasitic infection? Female Reproduction What age were you when you first got your period? Have your periods ever stopped? If yes, what age and for how long? Are your cycles regular? Your period cycle is days, and your period is present for (approx.) days. How heavy are your periods? What colour is the blood? Are there any clots? Do you have any spotting? Do you have cramps or pain associated with your periods? Do you have any pre-menstrual symptoms? (ie. water retention, breast tenderness, irritability, depression, headaches, mood swings, crying, acne, bloating, cravings, etc) Please describe: Number of pregnancies What type (if any) of birth control do you use? Male Reproduction How often to you urinate? Do you need to void through the night? Has this increased at all over the past 2 years? Have you ever had any prostate problems? Have you ever had your prostate examined? If so, when? Do you have anything else you would like to comment on or discuss with the doctor? Thank you for taking the time to fill out the intake form, this will help us to ensure you receive the best care, we look forward to helping you obtain your health goals. pg. 5

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