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O Arteriosclerosis

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					                                                                 Health In Your Hands  302 Orchard Road #06-03 Singapore 238862
                                                                      Phone: (+65) 6884 9820  Email: scoliosis.feedback@gmail.com
                                                                                         www.scoliosis.com.sg


                                            PERSONAL HEALTH HISTORY
Patient’s Name _________________________________________________ DOB _________________ Date __________________

The following form is to be completed prior to your consultation and emailed to the above contact details. Upon receiving the
questionnaire, we will contact you via email to schedule your first consultation. Please complete the health history questionnaire. If you
have any test results, etc. please feel free to attach copies along with any pertinent information not covered here. All information will be
kept strictly confidential. Please check the degree of all conditions you currently have or have had. To be responsible for your case, we
need your complete health history.
                                  O = Occasional                F = Frequent                C = Constant
O F C                                  O F C                                    O F C                                Check any of the
Muscle / Joint                         Eye, Ear, Nose and Throat                Skin                                 following conditions
   Arthritis                           Asthma                                Boils                          you currently have
   Bursitis                            Colds                                 Bruise easily                  or have had:
   Foot trouble                        Crossed eyes                          Dryness
   Hernia                              Deafness                              Hives or allergy                  Alcoholism
   Low back pain                       Dental decay                          Itching                           Anemia
   Lumbago                             Earache                               Skin eruptions (rash)             Appendicitis
   Neck pain, stiffness                Ear discharge                         Varicose veins                    Arteriosclerosis
   Pain between shoulders              Ear noise                                                                  Cancer
                                          Enlarged glands                    Pain or numbness in                     Chicken pox
General                                   Enlarged thyroid                      Shoulders                         Cholera
   Allergy                             Eye pain                              Arms                              Cold sores
   Chills                              Failing vision                        Elbows                            Diabetes
   Convulsions                         Far sightedness                       Hand                              Diptheria
   Dizziness                           Gum trouble                           Hips                              Eczema
   Fainting                            Hay fever                             Legs                              Edema
   Fatigue                             Hoarseness                            Knees                             Emphysema
   Fever                               Nasal obstruction                     Feet                              Epilepsy
   Headache                            Near sightedness                      Painful tailbone                  Fever blisters
   Loss of sleep                       Nose bleeds                           Poor posture                      Goiter
   Loss of weight                      Sinus infection                       Sciatica                          Gout
   Nervousness, depression             Sore throat                           Spinal curvature                  Heart disease
   Neuralgia                           Tonsillitis                           Swollen joints                    Herpes
   Numbness                                                                  Respiratory                             Influenza
   Sweats                           Gastrointestinal
                                                                                   Chest pain                        Lumbago
   Tremors                             Belching or gas                                                            Malaria
                                          Colitis                               Chronic cough
Cardiovascular                                                                     Difficult breathing               Measles
                                          Colon trouble                                                           
   Hardening of arteries               Constipation                          Spitting up blood                  Miscarriage
   High blood pressure                                                          Spitting up phlegm                Multiple sclerosis
                                          Diarrhea                                                                
   Low blood pressure                  Difficult digestion                   Wheezing                           Mumps
   Pain over heart                                                                                                   Pacemaker
                                          Bloated abdomen                    Women only                           
   Poor circulation                    Excessive hunger                      Congested breasts
                                                                                                                         Pleurisy
   Rapid heartbeat                                                                                                   Pneumonia
                                          Gallbladder trouble                   Cramps or backache                Polio
   Slow heartbeat                      Hemorrhoids                           Excess menstrual flow
   Swelling of ankles                                                                                                Rheumatic fever
                                          Intestinal worms                      Hot flashes                       Scarlet fever
Genitourinary                             Jaundice                              Irregular cycle                   Stroke
   Bed-wetting                         Liver trouble                         Lumps in breast                   Tuberculosis
   Blood in urine                      Nausea                                Menopause                         Typhoid fever
   Frequent urination                  Pain over stomach                     Painful menstruation              Ulcers
   Lack of kidney control              Poor appetite                         Vaginal discharge                 Venereal disease
   Kidney infection                    Vomiting                                                                   Whooping cough
   Painful urination                   Vomiting of blood                  Are you pregnant? Yes No
   Prostate trouble                                                          If yes, how many months?____
   Pus in urine                                                              How many children do you have?____

Describe your problem if scoliosis state the degree and type of curve:




How long have you had this condition?                    Is it getting worse?      Yes  No
Does it bother your (check appropriate box):  Work       Sleep  Other (please specify)
What seemed to be the initial cause?
Are you under the care of a physician?  Yes  No           If yes, for what reason?
                                                                  Health In Your Hands  302 Orchard Road #06-03 Singapore 238862
                                                                       Phone: (+65) 6884 9820  Email: scoliosis.feedback@gmail.com
                                                                                          www.scoliosis.com.sg



Have you been hospitalized in the last 5 years?  Yes  No       If yes, for major surgery?  Yes  No for serious injury?  Yes  No
Have you had any mental or emotional disorders?  Yes  No               If yes, when?
Indicate the drugs do you now take?  Birth control pills       Tranquilizers        Pain Killers      Other (specify)
Do you wear:  heel lifts?  sole lifts?  inner soles?  area supports?  negative heels?  platform shoes?
How is most of your day spent?  standing  sitting  walking  other (specify)

Have you ever:                                  Yes     No        If yes, briefly explain.
- had a broken bone?                                                                                HABITS        None Light Mod Heavy
- been hospitalized?                                                                                Alcohol                    
- had strains or sprains?                                                                           Coffee                     
- used a cane, crutch or other support?                                                             Tobacco                    
- been struck unconscious?                                                                          Drugs                      
- been hospitalized for other than surgery?                                                         Exercise                   
Do you:                                                                                               Sleep                      
- take minerals, herbs or vitamins?                                                                 Appetite                   
- think you need minerals, herbs or vitamins?                                                       Soft Drinks                
- have any drug allergy?                                                                            Salty Foods                
                                                                                                      Water                      
When did you last have:                         Never       0-6 mos.   6 -18 mos. longer
                                                                                                      Sugar                      
- spinal x-ray?                                                                  
- spinal examination?                                                                             Artificial
- physical examination?                                                                           Sweeteners                 


Please list any other health conditions you have been treated for, or surgery you have had in the last ten years.




FAMILY HEALTH HISTORY: Information about your immediate family members, brothers, sisters, parents, and grandparents will give
us a better understanding of your total health picture.
    RELATIONSHIP           PRESENT AND PAST HEALTH PROBLEMS




                                           Please mark your areas of pain on the figures below.
                                                   Draw your scoliosis if possible.