Adult Intake – digital - Dr. Vivian Lord_ ND by yaosaigeng


									                                    Adult Health Questionnaire

Name: (Last)              (First)         (Middle Initial)
Date: (mm/dd/yyyy)
City:       State/Province:                Zip/Postal code:
Telephone # (cell):             Alt. #:          Please indicate primary contact number
E-mail Address:                       Skype Username (if choosing appointments via Skype):
Date of Birth: (mm/dd/yyyy)                 Age:         Gender: Female     Male
Marital Status:       S        M       W       D # of children:

Occupation:           Hours per week:                Retired:
Employer:           Work #:
Work Address:

Next of kin or other to reach in case of an emergency:
Relationship:         Phone #:

Medical Doctor:
Name:           Telephone:
Date of Last Appointment:                  Date of Last physical:
Date of Last Dental Exam:

How did you hear about Dr. Lord?
Has any other family member been seen by Dr. Lord?

             Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023
           Phone: (917) 767-3652 Email: Website:
                                 CONTEXT OF CARE REVIEW

Successful health care and wellness are only possible when I have a complete understanding
of you physically, mentally and emotionally. The nature of your responses to the following
questions will go a long way in assisting my understanding of your truest desires and will
greatly aid me to assist your health needs.

1)   a) Why did you choose to see Dr. Lord?

     b) What do you know about her approach?

2) a) What three expectations do you have from this first appointment?

     b) What long term expectations do you have of me personally as your healthcare

3) What is your present level of commitment to address any underlying causes of your sign
   and symptoms that relate to your lifestyle? (Rate from 0 – 10, with 10 being 100%

     0%    0     1     2     3     4     5     6    7     8      9     10 100%

4) a) What behaviours or lifestyle habits do you currently engage in regularly that you
   believe support your health? (please list)

     b) What behaviours or lifestyle habits do you currently engage in regularly that you
     believe are less constructive lifestyle habits? (please list)

5) What potential obstacles do you foresee in addressing the lifestyle factors that are
   undermining your health and in adhering to the therapeutic protocols that we will be
   sharing with you?

6) Who do you know that will sincerely and consistently support you with the beneficial
   lifestyle changes you will be making?

          Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023                      2
Phone: (917) 767-3652 Email: Website:
What are your most important health problems? List as many as you can in order of


What are your most important health goals?


                                        FAMILY HISTORY

Do you have a family history of any of the following? (please fill in all applicable boxes)

              Relationship    Comments                           Relationship     Comments
Allergies                                        Heart
Anemia                                           Hepatitis
Arthritis                                        High blood
Auto                                             Kidney
immune                                           disease
Asthma                                           Mental
Cancer                                           Stroke
Diabetes                                         Tuberculosis
Epilepsy                                         Other

Any other relevant family history?

                                     CHILDHOOD ILLNESSES

Please check whether you had any of these as a child:
   Scarlet fever                 Rheumatic fever                      Measles
   Diphtheria                    Mumps                                German measles

          Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023                          3
Phone: (917) 767-3652 Email: Website:

Are you hypersensitive or allergic to…
Environmental or chemical?

                           HOSPITALIZATIONS, SURGERY, IMAGING

What hospitalizations, surgeries, X-Rays, CT scans, EEG, EKG’s have you had?

      year:                                                year:

      year:                                                year:

      year:                                                year:

                         CURRENT MEDICATIONS & SUPPLEMENTS

Do you take or use? (Please check Yes or No)

                         Y     N                            Y      N                      Y   N
Pain Relievers                           Laxatives                        Antibiotics
Appetite suppressant                     Cortisone                        Tranquilizers
Thyroid Medication                       Sleeping Pills                   Antacids

Please list any prescription medications, over the counter medications, vitamins or other
supplements you are taking

1)       Dosage:                                  5)            Dosage:
2)       Dosage:                                  6)            Dosage:
3)       Dosage:                                  7)            Dosage:
4)       Dosage:                                  8)            Dosage:

                        (Chiropractic/ Naturopath/Massage/ Other)

Name:         Telephone:


Height:      Weight:         Weight 1 year ago:             lbs
Maximum Weight:          When:
When during the day is your energy the best?              Worst?

          Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023                              4
Phone: (917) 767-3652 Email: Website:
                                   TYPICAL FOOD INTAKE

To Drink:


For the following, please check:

Y = Presently have N = Never had P = Significant problem in the past

Main exercise and hobbies:
                            Y      N   P                                   Y    N    P
Do you exercise                               Enjoy your work
If yes, what kind?                            Take vacations
       - How often                            Spend time outside
Average 6-8 hrs sleep                         Watch television
Sleep well                                       - How many hours/week
Awaken rested                                 Read
Have a supportive                                - How many hours/week
Have a history of abuse                       Do you eat 3 meals a day
Any major traumas                             Do you go on diets often
Use recreational drugs                        Do you eat out often
Been treated for drug                         Do you drink coffee
Treated for alcoholism                        Drink black/green tea
Do you use tobacco                            Do you drink soda
Smoked previously?                            Do you eat refined sugar
    - How many years                          Any foods you crave:
    - How many packs per day                  Any dietary restrictions or regimens you

          Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023                     5
Phone: (917) 767-3652 Email: Website:
                                   REVIEW OF SYSTEMS

Y = Presently have N = Never had P = Significant problem in the past

                            Y     N     P                                         Y   N       P
Chills or fever                                          Unusual weight loss
Unusual weight gain                                      Night sweats
Swollen lymph nodes                                      Weakness or fatigue

                                       Mental/ Emotional
                            Y     N     P                                         Y   N       P
Treated for emotional                                Depression
Mood swings                                              Anxiety or nervousness
Considered/ Attempted                                    Tension
Poor concentration                                       Memory problems

                            Y     N     P                                         Y   N       P
Hypothyroid                                              Heat or cold
Hypoglycemia                                             Diabetes
Excessive thirst                                         Excessive hunger
Fatigue                                                  Seasonal depression
Hair texture change

                            Y     N     P                                         Y   N       P
Seizures                                                 Paralysis
Muscle weakness                                          Numbness or tingling
Loss of memory                                           Easily stressed
Vertigo or dizziness                                     Loss of balance

                            Y     N     P                                         Y   N       P
Rashes                                                   Eczema, Hives
Acne, Boils                                              Itching
Color change                                             Perpetual hair loss
Lumps or growths                                         Night sweats
Bruise easily                                            Unusually dry

                            Y     N     P                                         Y   N       P
Headaches                                                Head injury

          Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023                      6
Phone: (917) 767-3652 Email: Website:
Migraines                                            Jaw/TMJ problems

                         Y   N     P                                        Y   N       P
Spots in eyes                                        Cataracts
Impaired vision                                      Glasses or contacts
Blurriness                                           Eye pain/strain
Color blindness                                      Tearing or dryness
Double vision                                        Glaucoma

                         Y   N     P                                        Y   N       P
Impaired hearing                                     Ringing
Earaches                                             Dizziness

                                  Nose and Sinuses
                         Y   N     P                                        Y   N       P
Frequent colds                                  Nose bleeds
Stuffiness                                      Hayfever
Sinus problems                                  Loss of smell

                                  Mouth and Throat
                         Y   N     P                                        Y   N       P
Frequent sore throat                            Copious saliva
Teeth grinding                                  Sore tongue/lips
Gum problems                                    Hoarseness
Dental cavities                                 Jaw clicks

                         Y   N     P                                        Y   N       P
Lumps                                                Swollen glands
Goiter                                               Pain or stiffness

                         Y   N     P                                        Y   N       P
Cough                                                Sputum
Spitting up blood                                    Wheezing
Asthma                                               Bronchitis
Pneumonia                                            Pleurisy
Emphysema                                            Difficulty breathing
Pain on breathing                                    Shortness of breath
Shortness of breath at                               Shortness of breath
night                                                lying down

                         Y   N      P                                  Y        N       P
Heart disease                                    Angina
High/Low blood pressure                          Murmurs
            Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023              7
Phone: (917) 767-3652 Email: Website:
Blood clots                                        Fainting
Phlebitis                                          Palpitations/ Fluttering
Rheumatic fever                                    Chest pain
Swelling in ankles

                            Y   N    P                                     Y      N       P
Trouble swallowing                                 Heartburn
Change in thirst                                   Abdominal pain or
Change in appetite                                 Belching or passing gas
Nausea/ vomiting                                   Constipation
Ulcer                                              Diarrhea
Jaundice (yellow skin)                             Bowel movments: how often:
Gall bladder disease                                  - is this a change?
Liver disease                                      Black in stool
Hemorrhoids                                        Blood in stool

                            Y   N    P                                        Y   N       P
Pain on urination                                  Increase frequency
Frequency at night                                 Inability to hold urine
Frequent infections                                Kidney stones

                            Y   N    P                                        Y   N       P
Joint pain or stiffness                           Arthritis
Broken bones                                      Weakness
Muscle spasms or cramps                           Sciatica

Loss of muscle mass

                                Blood/ Peripheral Vascular
                            Y   N    P                                        Y   N       P
Easy bleeding or bruising                           Anemia
Deep leg pain                                       Cold hand/feet
Varicose veins                                      Thrombophlebitis

                                    Male Reproductive
                            Y   N    P                                        Y   N       P
Hernias                                           Prostate disease
Testicular pain                                   Discharge or sores
Venereal disease                                  Chlamydia
Are you sexually active                           Gonorrhea
Impotence                                         Condyloma
Premature ejaculation                             Herpes

          Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023                  8
Phone: (917) 767-3652 Email: Website:
Birth control? Type                                    Syphilis
Testicular masses

                                Female Reproduction/Breasts
                            Y     N   P                                      Y    N       P
Age of first menses                                Date of last annual exam/ PAP:
Age of last menses (if menopausal)                   - Are cycles regular?

Days between period                days                Bleeding between
Duration of period                days                 Pain during intercourse

Painful menses                                         Clotting
Heavy or excessive flow                                Discharge
PMS                                                    Birth control
If yes, what are your symptoms?                          - What type
                                                       Number of pregnancies:
Endometriosis                                          Number of live births:
Ovarian cysts                                          Number of miscarriages:
Difficulty conceiving                                  Number of abortions:
Cervical dysplasia                                     Menopausal symptoms
Sexual difficulties                                    Abnormal PAP
Gonorrhoea                                             Chlamydia
Herpes                                                 Condyloma
Are you sexually active                                Syphilis
Do you so self breast                                  Breast lumps
Breast pain/tenderness                                 Nipple discharge

Is there anything else you would like to add or comment on?

                            Thank you for your time and effort.

                I look forward to providing you with the best possible care.

          Vivian Lord, N.D. LLC 228 W71st Street, New York, NY 10023                  9
Phone: (917) 767-3652 Email: Website:

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