Front St Suite Sheppard Ave Suite Bay

Document Sample
Front St Suite Sheppard Ave Suite Bay Powered By Docstoc
					                     DETAILED MEDICAL
Please check all medical conditions below that apply to you or any member of your family:
AIDS / HIV               Present        Past       Family       Liver Disease                   Present   Past    Family
Asthma / Emphysema       Present        Past       Family       High Blood Pressure             Present   Past    Family
Alcoholism/Drug Use      Present        Past       Family       High Cholesterol                Present   Past    Family
Allergies                Present        Past       Family       Irritable Bowel Syndrome        Present   Past    Family
Arthritis                Present        Past       Family       Kidney Disease                  Present   Past    Family
Cancer                   Present        Past       Family       Lung Disease                    Present   Past    Family
Chronic Fatigue          Present        Past       Family       Multiple Sclerosis              Present   Past    Family
Crohn’s or Colitis       Present        Past       Family       Obesity                         Present   Past    Family
Depression               Present        Past       Family       Osteoporosis                    Present   Past    Family
Diabetes                 Present        Past       Family       Seizures                        Present   Past    Family
Fibromyalgia             Present        Past       Family       Skin Condition (eg. eczema)     Present   Past    Family
Hemophilia               Present        Past       Family       Stomach Ulcers                  Present   Past    Family
Heart Attack / Stroke    Present        Past       Family       Stroke                          Present   Past    Family
Hepatitis                Present        Past       Family       Thyroid Disease                 Present   Past    Family
Surgeries             Specify:
Major Trauma(s)       Specify:
Other                 Specify:

Women –         Are you currently pregnant?                 Y         N        Possible
Allergies – Please list any allergies, sensitivities, or food intolerances (include drugs, foods, environment, etc)

Nutrition:     # of caffeinated beverages per day                       Cups of water per day
Please list the food and beverages you’ve consumed for the past 3 days, be as specific as possible
                           Day 1                                  Day 2                           Day 3




Lifestyle Habits:
Do you exercise regularly?         Y       N            What form of exercise?
Hours of sleep per night                                Time do you go to bed?
Do you smoke cigarettes?           Y       N            How many per day
Using the Stress Scale, please rate your stress level by circling a number below:
               1        2          3           4      5                6        7         8        9        10
         no stress                                 moderate                                       extremely stressed

                156 Front St W, Suite 305 | 25 Sheppard Ave W, Suite 300 | 330 Bay St, Suite 820 Toronto ON
                    Phone: 416-646-6783 | Fax: 416-363-0406 | |
Other Symptoms and Secondary Complaints – Please check all that apply:
Head                           Heart and Thorax                Gastrointestinal                Women’s issues
   Headaches                      Palpitations                    Bad breath                      Fibrocystic breasts
   Migraines                      Rapid heart beat                Poor appetite                   Breast tenderness
   Dizziness                      Tightness in chest              Excessive hunger                Fertility problems
   Memory Loss                    High blood pressure             Excessive thirst                Ovarian cysts
   Concussions                    Low blood pressure              Belching                        Endometriosis
Other                             Arteriosclerosis                Heartburn                       Hot flashes
                                  Prior heart attack              Gas                             Vaginal discharge
Eyes                           Other                              Abdominal pain                  Low sex drive
   Blurred vision                                                 Parasites                       PMS
   Pain                        Respiration                        Nausea                          Painful menses
   Dryness                        Bronchitis                      Constipation                    Irregular cycle
   Redness                        Chest pain                      Chronic laxative use            Excessive flow
   Glasses/lenses                 Difficulty breathing            Loose stools/diarrhea           Light flow
   Eyestrain                      Pneumonia                       Bloody/black stools             Clotting
   Color blindness                Wheezing                        Hemorrhoids                     Abnormal bleeding
   Night blindness                Chronic cough                   Rectal pain                  Age of first menses
   Cataracts                      Coughing blood                  Gallbladder trouble          Duration of period
   Spots in front of eyes         Phlegm                       Other                           Cycle length
Other                          Phlegm color:                                                   # Pregnancies
                               Other                           Urogenital                      # Births
Ears                                                              Frequent urination           # Miscarriages
   Poor hearing                Neuromuscular/Skeletal             Difficulty urinating         # Abortions
   Ringing                        Stiff neck                      Burning urination            # Premature births
   Frequent ear infections        Low back pain                   Frequent UTIs                # Cesarean sections
Other                             Shoulder trouble                Waking to urinate            Birth control
                                  Spinal curvature                Retention of urine           Other
Nose / Throat                     Pain between shoulders          Dribbling of urine
   Frequent colds                 Swollen joints                  Bedwetting                   Men’s issues
   Sinus trouble                  Painful joints                  Pause of urination flow         Prostate problems
   Allergies                      Hip pain                        Itching of genitals             Discharge
   Nosebleeds                     Hand/wrist pain                 History of STD’s                Impotence
   Drainage                       Knee pain                    Other                              Frequent emissions
   Sore throat                    Sprain                                                          Fertility problems
   Difficulty swallowing          Hernia                       Sleep                              Ejaculatory problems
Other                             Sciatica                        Insomnia                        Painful/swollen testes
                                  Numbness or tingling            Drowsiness                   Other
Mouth                             Paralysis                       Night sweats
   Gum problems                Other                              Sleepwalking                 Emotional
   Teeth problems                                                 Excessive dreaming              Depression
   Tongue/lip sores            Skin                               Not enough sleep                Anxiety
   Jaw clicking/pain              Rash                         Other                              Anger
   Unusual tastes                 Dryness                                                         Mood swings
Other                             Hives                        Energy level                       High stress
                                  Itching                         Low energy                      OCD
Circulation                       Night sweats                    Excessive energy                ADD/ADHD
   Bruise easily                  Acne                            Wake tired in morning           Mania/bipolar
   Cold hands and feet            Recent moles                    Low afternoon energy         Other
   Fainting                       Excessive sweating              Sudden energy drops
   Phlebitis                      Dandruff                        Feel tired all the time
   Varicose veins                 Hair loss                       Chronic fatigue
   Anemia                         Change in hair texture          Excessive yawning
Other                          Other                           Other

                 156 Front St W, Suite 305 | 25 Sheppard Ave W, Suite 300 | 330 Bay St, Suite 820 Toronto ON
                     Phone: 416-646-6783 | Fax: 416-363-0406 | |

Shared By: