Patient Health History by HC120830235414


									                                                             WELLNESS EVALUATION

Name: ____________________________________________________                                    Today’s Date: ______/______/______
                  (first)               (middle)                    (last)

A successful rejuvenation and preventative medicine package is only possible when the practitioner has a complete understanding of
the client physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information
and indicate areas of confusion with a question mark. Thank you.

    1.   When and where did you last receive health care and for what reason?


    2.   Name of primary health clinic/doctor: _________________________________ Phone #_______________________________

    3.   Please identify the health concerns that have brought you to the clinic in order of importance below:

         Condition/Reason for Visit Today                                                     Past Treatment

         a. ____________________________                            ________________________________________________________

                  How does this condition affect you? ____________________________________________________________

         b. ____________________________                            ________________________________________________________

                  How does this condition affect you? ____________________________________________________________

         c. ____________________________                            _______________________________________________________

                  How does this condition affect you? ____________________________________________________________

4. If applicable, please list any foods, drugs, or medications you are hypersensitive or allergic to (please include reaction):



5. Please list any medications (prescribed and over-the-counter), vitamins, and supplements you are currently taking:



6. Do you have any infectious diseases?            Y         N      If yes, please identify: ______________________________________

7. Circle any that apply to you:
    Pacemaker        Cochlear Implant                  Diabetes          HIV/AIDS         Seizures   TB    CHEMO/RAD

     Hemophilia              Hepatitis A B             C     Hypertension        Cancer   Blood Thinning Meds         Pregnant

8. Family History:                    Father                Mother             Brothers            Sisters               Spouse             Children
Age (if living)                       _______               ________           ________            ________              ________           _______
Health (Excellent, Fair, Poor)        _______               ________           ________            ________              ________           _______
Age or Cause of Death                 _______               ________           ________            ________              ________           _______

9 . Childhood Illness (please circle any that you have had):

    Scarlet Fever      Diphtheria           Rheumatic Fever          Mumps            Rubella/Measles           Chicken Pox          Other__________

10. Immunizations (please circle any that you have had):

    Polio           Tetanus           Measles/Rubella/Mumps             Pertusis           Diphtheria          Hib         Hepatitis B

    Others: __________________________________________________________________________________________________

11. Hospitalizations and Surgeries: _______________________________________________________________________________



12. Emotional ( 12-26 please circle any that you experience now ):

    Mood Swings                Irritable          Mental Tension           Anxiety       Depression          Bipolar       Excess Grief

13. Energy and Immunity

   Fatigue              Slow Wound Healing           Chronic Infections            Fatigue after eating         Chronic Fatigue Syndrome

14. Head, Eye, Ear, Nose,Throat

Impaired Vision        Eye Pain/Strain           Glaucoma            Glasses/Contacts        Tearing/Dryness           Excess Thirst      Lack of thirst

Impaired Hearing              Ear Ringing        Earaches            Headache             Tongue/mouth sores            Flushed face

Nose Bleeds       Bleeding gums       Frequent Sore Throats          Teeth Grinding       TMJ/Jaw Problems               Hay Fever     Sinus Problems

15. Respiratory/Chest

         Pneumonia        Frequent Colds         Difficulty Breathing          Emphysema       Asthma/Wheezing

         Persistent Cough             Pleurisy              Tuberculosis       Sensation of object in Throat         Sore throat

         Shortness of Breath        Fullness in Chest       Palpitations       Sighing      Allergies        Bronchitis

16. Circulatory/Cardiovascular

         Heart Disease        Chest Pain         Swelling of Ankles            High Blood Pressure           Palpitations/Fluttering     Stroke

         Heart Murmurs        Rheumatic Fever               Varicose Veins           Always Cold      Cold Limbs         Cold Hands/Feet

17. Digestive System

Ulcers     Acid reflux    Changes in Appetite       Nausea       Vomiting       Uppergastric Pain      Heartburn      Always Hungry

Belching        Gall Bladder Disease       Liver Disease         Bloody Stools      Hemorrhoids        Abdominal Pain         Diarrhea

Constipation         Alternating Constipation/Diarrhea             Undigested food in stools        Poor appetite      No appetite

18. Genito-Urinary Tract

         Kidney Disease         Painful Urination     Cloudy Urine           Frequent UTI        Frequent Urination     Heavy Flow

         Kidney Stones         Impaired Urination     Blood in Urine            Frequent Urination at Night           Dark Urine

19. Female Reproductive/Breasts

Irregular Cycles Breast Lumps/Tenderness Nipple Discharge           Heavy Flow Low Libido           Vaginal Discharge     Pre-menstrual

Problems Clotting Bleeding Between Cycle Menopausal Symptoms Difficulty Conceiving                     Painful Periods STDs(herpes,warts etc)

 Do you have any reason to believe you may be pregnant? Y N            If Yes, what is your expected due date ___________

20. Menstrual/Birthing History:

         1. Age of First Menses: _______              4. Birth Control Type: ___________            7. Last Pap:______Results:______

         2. # of Days of Menses: _______              5. # of Pregnancies: _____________

         3. Length of Cycle: ___________              6. # of live births: ______________

21. Male Reproductive

         Sexual Difficulties         Prostate Problems                      Testicular Pain/Swelling             Penile Discharge

         Impotence                   STDs (herpes, warts etc.)              Low sex drive           Other__________________

22. Musculoskeletal

         Neck/Shoulder Pain          Muscle Spasms/Cramps                   Arm Pain         Upper Back Pain              Mid Back Pain

         Low Back Pain               Leg Pain         Weak/Sore Knees               Joint Pain (if so, where?): ______________________

23. Neurologic

Vertigo/Dizziness        Paralysis     Numbness/Tingling         Loss of Balance         Seizures/Epilepsy        Poor memory

24. Endocrine

  Hypoglycemia       Hypothyroid     Hyperthyroid    Diabetes Mellitus        Night Sweats     Spontaneous Sweats       Feeling Hot or Cold

25. Sleep Patterns

 Difficulty Falling Asleep      Difficulty Staying Asleep        Insomnia     Wakes Un-rested       Nightmares       Dream disturbed sleep

26. Dermatology

 Brittle nails    Dry Skin         Itchy Skin        Psoriasis         Rashes     Eczema      Loss of hair    Acne

27. Lifestyle/Nutrition:

        a.   How often do you eat?    Every________hours.

        b.   Do you experience any of the following after eating? Lethargy_____ Energized_____ Acid reflux_______

        c.   How much of the following substances do you consume daily?

        Dairy Products (milk, cheese,
        yogurt, butter, ice cream, etc.)_____________________________________________________

        Meats / fish / poultry: ____________________________________________________________

        Breads & grains:________________________________________________________________

        Cooked vegetables:______________________________________________________________

        Raw fruit / vegetables:___________________________________________________________

        Specific food / flavor cravings:_____________________________________________________

        Daily sugar intake:____________________________________________________________________

        d.   Exercise routine: _________________________________________________________________________________

        e.   How many hours per night do you sleep? ________           Do you wake rested?   Y       N

        f.   Forms and how often of following: Nicotine______________ Alcohol _____________Caffeine ______________

        g.   How much water do you drink per day?__________

        h.   Interests and hobbies: _________________________________________________________________________________

28. How much participation are you willing put forth to better your own health?
29. Comments or questions can be addressed here.


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