General Information Name Age Today s Date Date of Birth Email Address City State Zip Phone (Home) (Cell) (Work) Genetic Background: Caucasian African American Hispanic Mediterranean Asian Native American European Other When, where and from who did you last receive medical or health care? Emergency Contact: Relationship Phone (Home) (Cell) (Work) How did you hear about our practice? Clinic website Referral from doctor Referral from friend/family member Social media Other Current Health Concerns Please rank current and ongoing health concerns in order of priority Description of problem Mild Moderate Severe Prior Treatment approach and outcome Excellent Good Fair Example: eczema x Steroid cream x 1. 2. 3. 4. 5. 1
Health Goals When was the last time you felt well? What makes you feel better? What makes you feel worse? How does your condition affect you? Did something trigger your change in health? What do you feel needs to happen for you to get better? Are there things that stop you from making the necessary changes to feel better? What do you hope to achieve in your visit with us? Current occupation: Previous occupations: 2
Readiness Assessment and Health Goals Rate on a scale of 5 (very willing) to 1 (not willing): In order to improve your health, how willing are you to: Significantly modify your diet Take several nutritional supplements each day Keep a record of everything you eat each day Modify your lifestyle (e.g. sleep habits) Practice a relaxation technique Engage in regular exercise Rate on a scale of 5 (very supportive) to 1 (very unsupportive): At the present time, how supportive do you think the people in your household will be to your implementing the above changes? Lifestyle Review Sleep How many hours of sleep do you get each night on average? Do you have daytime sleepiness? Do you have problems falling asleep? Do you have problems staying asleep? Do you have problems with insomnia? Do you snore? Do you feel rested upon awakening? Do you use sleeping aids? If yes, explain: Do you have sleep apnea? If yes, do you use CPAP routinely? Exercise Do you currently exercise: Yes A little No Current Exercise Program: Do you feel motivated to exercise? Yes A little No Are there any problems that limit exercise? If yes, explain: Do you feel unusually fatigued or sore after exercise? If yes, explain: Nutrition Do you currently follow any of the following special diets or nutritional programs? (Check all that apply) Vegetarian Vegan Allergy Elimination Low Fat Low Carb High Protein Blood Type Gluten Free No Dairy No Wheat Low sodium Other: Do you have sensitivities to certain foods? 3
If yes, list food and symptoms: Do you have any food allergies? If yes, list foods: Are there any foods that you crave or binge on? If yes, what foods? Do you eat 3 meals a day? If no, how many meals per day do you eat? Any lifestyle or other barriers to healthy eating? If yes, please explain: Cans of soda (regular or diet) Number of glasses of water per day: 1-2 3-4 5-6 7-8 >8 Stress Do you feel you have an excessive amount of stress in your life? Do you feel you can easily handle the stress in your life? How much stress does each of the following cause on a daily basis (Rank on scale of 1-10, 10 being highest) Work Family Social Finances Health Other Do you use relaxation techniques? If yes, how often? Which techniques do you use? (Check all that apply) Meditation Breathing Tai Chi Yoga Prayer Other: Have you ever sought counseling? Have you ever been abused, a victim of crime, or experienced a significant trauma? What are your hobbies or leisure activities? Do you have resources for emotional support? (Check all that apply) Spouse/Partner Family Friends Religious/Spiritual Pets Other: Do you have a religious or spiritual practice? If yes, what kind? 4
Relationships Marital status: Single Married Divorced Gay/Lesbian Long-Term Partner Widow/er With whom do you live? (Include children, parents, relatives, friends, and pets) History Patient s Birth/Childhood History: You were born: Term Premature Don t know Were there any pregnancy or birth complications? If yes, explain: You were: Breast-fed Bottle-fed Don t know As a child, were there foods you avoided because they gave you symptoms? If yes, what foods and what symptoms? (Example: milk gas and diarrhea) Dental History: Check if you have any of the following: Silver mercury fillings Gold fillings Root canals Implant Caps/Crowns Tooth pain Bleeding gums Gingivitis Have you had any mercury fillings removed? If yes, when: Environmental/Detoxification History Do any of these significantly affect you? Cigarette smoke Perfume/colognes Auto exhaust fumes Other Current or historical exposure to: (Check all that apply) Mold Water leaks Damp environments Renovations Carpets or rugs Paints Pesticides Herbicides Cleaning chemicals Heavy metals (lead, mercury, etc.) Harsh chemicals (solvents, glues, gas, acids, paint thinner, etc.) Have you had a significant exposure to any harmful chemicals? If yes: Chemical name, length of exposure, date: Any significant exposure to mold? Do you have any pets or farm animals? If yes, do they live: Inside Outside Both What kind of pet: Did you grow up on a farm or city? 5
Tobacco and Alcohol History Currently use tobacco products? If yes, what kind? If you have quit, what was your quit date? Current alcohol use? If yes, number of servings per week? 1-2 3-4 5-6 7-8 >8 Other History of tick bites or tick exposure? If yes, did you have any rash? Were you ever treated with antibiotics? What state did tick bite occur? Antibiotic history: >5 times as a child: > 5 times as a teen: >5 times as an adult: Steroid history: >5 times as a child: > 5 times as a teen: >5 times as an adult: Routine non-steroidal anti-inflammatory use like motrin, advil or alieve: Routine acid blocker use like zantac, Prilosec, protonix, omeprazole: Immunosuppression therapy: 6
Women s History Obstetric History: (Provide number if applicable) Pregnancies Abortions Living children Vaginal deliveries Cesarean Term births Premature birth Birth weight of largest baby Birth weight of smallest baby Menstrual History: Age at first period Date of last menstrual period Irregular periods: Painful menses: Heavy bleeding: Post-menopausal bleeding: Painful intercourse: Low libido: Urinary leakage: Breast tenderness: PMS symptoms: Hot flashes: Night sweats: Mood swings: Vaginal dryness: Ovarian cysts: Sexually transmitted disease: If yes, what type? Hysterectomy: Ovaries retained: Cervix present: Miscarriages: Past oral contraceptive use: Past hormone replacement: History of abnormal pap: History of abnormal mammogram: History of gestational diabetes or baby > 8lbs: History of infertility: Date of last Digital rectal exam: Personal history of Cancer: Self-Breast Exam: Gynecological Screening/Procedures: (If applicable, provide date) Last Pap test: Results: Normal Abnormal Last mammogram: Results: Normal Abnormal Last bone density: Results: Normal Abnormal Last colonoscopy: Results: Normal Abnormal Performed by whom: Other tests/procedures (list type and dates) 7
Men s History (Check box if applicable) Testicular mass Testicular pain Prostate enlargement Prostate infection Change in sex drive Loss of control of urine Vasectomy Difficulty obtaining or maintaining an erection Urinary urgency/hesitancy/change in stream Nocturia (urination at night) # of times per night Sexually transmitted disease: If yes, what type? Do you perform Self-Testicular exams? Screening/Procedures: (If applicable, provide date) Last PSA test: PSA Level: 0-2 2-4 4-10 >10 Last colonoscopy: Results: Normal Abnormal Performed by whom: Other tests/procedures (list type and dates, i.e. Bone density) 8
Medications Dose Frequency Reason for taking Supplements Dose Frequency Reason for taking Allergies: Foods, meds, supplements Reactions 9