Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address

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Transcription:

Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home Cell Work E-mail Children (if applies, please list names and ages) Emergency contacts (Name/phone/relationship) Medical History (for additional information, please attach an additional sheet) List other doctors and healthcare practitioners you are seeing (name/phone) Prescription drugs and over-the-counter medications you are currently taking Nutrition and herbal supplements you are currently taking (list by brand name, dosage and frequency) Medical History continued

Health Concerns (please list your concerns in order of importance and describe in detail the history of your symptoms and the effect they have on your life): Known allergies (drug, food, chemical and environmental) Former Treatments (please list both conventional and alternative treatments you have had and the effectiveness of each treatment) Date of last physical exam Performed by whom? Surgeries and/or hospitalizations (conditions and dates) Serious accidents and/or severe injuries(list any head injuries or broken bones with dates)

Pain Descriptions Diagram (mark an X on the diagram to indicate where you are currently experiencing pain, numbness and/or tingling) Rate your PAIN on a scale of 1 to 10 (1=least pain) How often do you have this pain? Is it consistent or does it come and go? Type of PAIN: Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling Other Activities that are PAINFUL: Sitting Standing Walking Bending Lying down Other Symptom and Infection History Have you had the following? (check all that apply) Alcoholism Anemia Anorexia/Bullimia Psychiatric Care Diabetes Arthritis Asthma Back Trouble Ulcers Epilepsy Bleeding/Bursting Blood Transfusion Breast Lump Prostate Problems Migraines Bronchitis (chronic) Cancer Cataracts Thyroid Disease Glaucoma Heart Disease High Blood Pressure Kidney Disease Hemorrhoids Emphysema High Cholesterol Liver Disease Mitral Valve Prolapse Low Blood Pressure Gout Multiple Sclerosis Varicose Veins Hives/Eczema Hernia Migraines Pacemaker Stroke Other: AIDS/HIV Bladder Infections Bronchitis Chicken Pox Diphtheria Hepatitis Herpes Measles Mono Mumps Pneumonia Polio Rheumatic Fever Scarlet Fever Rubella Shingles Typhoid Fever Tonsillitis Tuberculosis Sinusitis Vaginal Infections Whooping Cough Sexually Transmitted For Women Age at first period Last pap Period frequency (ie; 28 days?) Ever have an abnormal pap? Yes No Days of flow If YES, describe Any problems with PMS Any irregularities with periods Do you do self breast exams? Yes No Last menstrual period Last mammogram Extreme menstrual pain? Yes No History of breast lump? Yes No Any history of infertility? Yes No If YES, describe Any hot flashes or night sweats? Yes No Are you experiencing any sexual dysfunction? Yes No List each pregnancy including abortions, miscarriages and births with dates. If complications with pregnancy or delivery including C-section, please describe:

For Men Last prostate exam Number of times you get up at night to urinate Last PSA Are you experiencing any sexual dysfunction? Yes No If YES, describe Medical Services Please indicate the date you last received the following or put N/A for services that do not apply to you. Tetanus Shot Flu Shot Pneumonia Shot Blood Tests EKG Chest X-ray Colonoscopy Lifestyle Diet Do you have any dietary restrictions? Coronary Calcium Score Do you have any cravings for any particular type of food (be specific) Are you satisfied with your diet? Yes No If NO, please explain How much water do you drink daily? What did you eat yesterday? (be specific) Breakfast Lunch Dinner Drink Do you drink alcohol? Indicate what type and what frequency per week If you used to drink but quit, please indicate date of quitting Other liquids? Do you drink caffeine? Indicate type and frequency per week Smoking/Chewing Tobacco and Drugs If you currently smoke/chew please indicate what you use and frequency per day Are you a former smoker? Please indicate date of quitting Do you use recreational drugs? Please indicate type and frequency per week Weight Usual weight? Are you happy with your weight? Yes No Sleep and Exercise How much sleep do you get per night? Do you feel rested? Yes No Please describe the exercise you do each week and include minutes per session and days per week: Do you enjoy exercise? Stress Level and Stress Reduction Describe your stress level (check one) NONE MILD MODERATE SEVERE Describe any stress reduction you practice including minute per session and frequency:

Lifestyle continued Daily and New Routines Do you enjoy your work/what you do during the day? Do you enjoy the people/pets in your life? Do you live near an agricultural/industrial area? Do you use paint, chemicals or solvents at home, for hobbies or during work? Have you moved to a new home recently? Have you done any remodeling recently Do you have any mold in your home or work area? Do you suffer from allergies? How many times have you used antibiotics in the past two years? List dental history and procedures: List any cosmetic surgery or procedures List travel history and vaccinations Family History Please include any family member who has had the following illnesses: Allergies/Asthma Arthritis Cancer Diabetes Gout High Blood Pressure Kidney Disease Migraines Stroke Other Relationship Anemia Bleeding Depression Drugs/Alcohol Heart Disease High Cholesterol Mental Illness Obesity Thyroid Disease Relationship Current status of family members (please include present age, or age and cause at death and if living indicate level of health as good, fair or poor) Paternal Grandmother Paternal Grandfather Maternal Grandmother Maternal Grandfather Father Mother Siblings Spouse Children Are you considering Dr. Thoring as your Primary Doctor? Yes No

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