Adult Health Summary

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Adult Health Summary Name: Date: Date of birth Home ph: May I call you at this number? Age Work ph: May I call you at this #? Cell ph: May I call you at this number? E-mail: May I contact you via e-mail? Address City, State, Zip Who may we thank for referring to our office? Past Medical History Put an X by things you have had in the past. Write in the year the condition started. Put a C for things you are currently experiencing. AIDS Congestive Heart Failure HIV positive Rheumatoid arthritis Alcoholism Depression Joint replacement Scarlet fever Anemia Diabetes Kidney Disease Sexually transmitted disease Anorexia Drug Dependent Liver Disease Stroke Anxiety Emphysema Measles Suicide attempt Appendicitis Epilepsy Migraines Suicide thoughts Arthritis Glaucoma Miscarriage Thyroid problems Asthma Gonorrhea Mononucleosis Tonsillitis Bleeding Disorders Gout Multiple Sclerosis Tuberculosis Blood in urine High blood pressure Mumps Ulcers Breast Lump Heart murmur Panic Attacks Unconsciousness Bronchitis Hepatitis Pacemaker Vaginal Infections Bulemia Hernia Pneumonia Other: Cancer Herpes Polio Cataracts Hiatal Hernia Psychiatric care Coma High Cholesterol Rheumatic Fever Surgery Past Surgeries/Procedures (Include Dental ex. Root canal, teeth pulled) Date Trauma History Check (X) any box which apply and explain circumstances and when occurred. Motor vehicle accident if so, when Fall if so, when, how high and injuries? Other trauma/injuries: Alcohol Cigarette-- Recreational drug use Occupation: Marital Status: Religious/spiritual preference: Social History Check (X) any box that applies # drinks/day or week # packs/day or week

What do you do for exercise? How often do you exercise? How long do you exercise? Exercise Check (X) any box that applies # days/week Minutes/day Medication/Herbal/Supplements Medications/Herbals/Supplements dose and frequency, when started Start Allergies List any medications, foods, environmental allergies and the reaction. Family History If any blood relative has suffered from any of the following, please check (X) and indicate the relative Allergies Cancer---what type Heart disease Asthma Diabetes High blood pressure Anemia Epilepsy/Seizure Kidney/bladder problems Arthritis Glaucoma Mental Illness Alcoholism Gout Stroke Blood Clotting Problems Headaches/migraines Other: Consultants--Please list other practitioners you see other physicians, chiropractors, acupuncturist etc and phone #

Review of Systems: Put an X by things you have had in the past. Write in the year condition started. Put a C for things you are currently experiencing. General Cardiac/vascular GU Skin/breast Fever Chest pain Bladder control Eczema Chills Chest pressure Blood in urine Hives Night Sweats Fainting Decrease force or urine Itching Weight Loss Heart murmur Painful intercourse Rashes Fatigue High blood pressure Painful urination Yellow skin/eyes Loss of energy Irregular heart beat Pelvic pain Breast lumps Loss of sleep Leg pain when walk Sexual dysfunction Nipple discharge Eye Lightheaded Urinary hesitancy Allergies/Immun Blurred vision Low blood pressure bedwetting Seasonal allergies Double vision Pass out Neurology Other allergies Crossed-lazy eye(s) Palpitations Cold or numb hands/feet Diet--# servings/day Eye pain Phlebitis Convulsions (seizures) Water Loss of vision Poor circulation Frequent headaches Coffee Visual Flashes Shortness of breath Muscle weakness Tea Visual Halos At rest Numbness/tingling Soda Had laser surgeries With exertion Tremors Meats Wear glasses or contacts Lying flat Unsteady walking Chicken Ear, Nose, Throat Swollen ankles Vertigo/spinning Fish Decreased hearing Varicose Veins Psychosocial Breads/cereal Earache Pulmonary Anxiety Dairy products Ear discharge Cough Depression Fruits Ear fullness Wheezing Nervousness Fruit juice Ear infections Gastrointestinal Behavior Vegetables Ear ringing-buzzing Abdominal pain Lack of emotional control Female only Hoarseness (prolonged) Black stools Irritable # of pregnancies Jaw Clicking Bloating Hyperactive # of live births Jaw locking Blood in stools Easily distracted # of miscarriages/abortions Nosebleeds Constipation Poor attention span # vaginal deliveries Post nasal drip Diarrhea Impulsive # c-sections Sinus problems Heartburn Endocrine Method of birth control Sore throat (frequent) Hemorrhoids Excessive weight gain Periods are: Swallowing difficulty Nausea Excessive weight loss Regular Vomiting Heat intolerance Irregular Heme/lymph Cold intolerance Painful Easy bruising Hair falling out Heavy Bleeding gums Excessive thirst Scant Lymph nodes

History of Present Illness: Please describe your problem(s) in as much detail as possible. If you have more than one problem, number each problem and answer each question separately for each issue. You may use a second sheet of paper if necessary. What all of symptoms are-- When symptoms began-- What makes it better What makes is worse How often do symptoms occur? How long do symptoms last when you get them-- Treatments tried and their effect on your problem -- All health care providers seen for this problem, the diagnosis they gave you, tests or x-rays done, and treatment given

Please answer yes or no to the following questions: Do you have a juicer? Do you have a blender, vitamix or blendtec? (circle one) Do you have a food dehydrator? Do you have a food processor? List what you typically have for breakfast, lunch, dinner and snacks. Include times when foods are eaten. Be specific if you have a sandwich, write down type of bread, meat, etc. If have cereal, what kind. What kind of milk do you drink (skim, whole, raw, pasteurized, almond milk etc). What do you put in your salads? What do you put on your veggies (ex. Butter, oil)? If you eat pizza, what is on the pizza?

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