20 MInutes Free Consultation

 

SHORT NEW PATIENT HISTORY FORM

NAME:_______________________________________ AGE: ___ DATE: __________    TIME: ________ am/pm

OCCUPATION:__________________________________________      

A.   MAJOR SYMPTOMS

Be a good storyteller.  What are your major symptoms and problems for which you have come to us today?  Please explain.  In describing your symptoms, think of duration, i.e., how long you have been having it, how severe it is, its frequency (how often you experience it).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. TREATMENT RECEIVED

    1. Tell us about the treatment you have received for the problems you have mentioned above, such as the physicians consulted, investigations, and the tests that you had (including x-rays, CT scans, blood tests), and medicines used - prescription or over-the-counter medicines, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.        Review of Systems:

 

Do you experience any of the following symptoms?  If so, rate each of the following symptoms based upon your typical health profile.

4 = Frequently have it, effect is severe

3 = Frequently have it, effect is not severe.

2 = Occasionally have it, effect is severe

1 = Occasionally have it, effect is not severe

0 = Never or almost never have the symptom

(Put your check rating in numbered column.)

1.

Digestive:

5.

Muscles/Joints:

 

Constipation

 

Muscle aches/muscle pain/muscle spasms; where:

 

Diarrhea or loose stool

 

forearms, fingers, thighs, legs/feet, neck

 

Gas

 

generalized (encircle all that apply)

 

Belching

 

Muscle cramps/charley horses

 

Bloating

 

Low back pain/spasm

 

Abdominal pain

 

Pain/tightness in upper back

 

White, coated tongue

 

Pain/tightness in neck, shoulder area

 

Heartburn

 

Joint pains, where:

 

Indigestion

 

Shoulders, elbows, wrists, hands, hips, knees, ankles,

 

Bad breath

 

foot, multiple joints (encircle all that apply).

 

 

 

 

2.

Headaches, Emotions, & Mind:

6.

Cardiovascular:

 

Headaches

 

High blood pressure 

 

Depression

 

Rapid heartbeat

 

Anxiety

 

Irregular or skipped heartbeat

 

Fear

 

Palpitations

 

Nervousness

 

 

 

Irritable or angry easily

7.

Nose:

 

Become aggressive easily

 

Stuffy nose 

 

“Fly off the handle”

 

Runny nose

 

Reduced memory

 

Hay fever

 

Reduced concentration

 

Sneezing attacks

 

Head pressure

 

Postnasal drip

 

Difficulty thinking clearly

 

Sinus infections

 

Mood swings

 

 

 

Difficulty in making decisions

8.

Lungs

 

Confusion

 

Wheezing

 

Poor comprehension

 

Asthma

 

Learning difficulties or learning disabilities

 

Difficulty in breathing

 

Hyperactivity

 

Chest tightness

 

Restlessness

 

Chest congestion

 

Insomnia

 

Shortness of breath

 

Drowsiness

 

Chronic cough

 

 

 

 

3.

Energy/Activity:

9.

Urinary Tract:

 

Tire easily/fatigue/low level of energy

 

Frequent urination

 

Tired by the end of the day

 

Burning on urination

 

Wake up tired

 

Awaken at night to urinate

 

Sleep excessively

 

 

 

Feel excessively cold

10.

For Women Only:

 

Weight gain

 

 

 

 

 

Have ever had vaginal yeast infection.  If yes, total

4.

Skin:

 

number of yeast infections in your lifetime ______.

 

Cold hands

 

Vaginal discharge

 

Cold feet

 

Premenstrual symptoms, a few to several days

 

Dry skin

 

before menstruation.  If yes, what premenstrual

 

Acne

 

symptoms do you have?

 

 

 

  • Premenstrual headaches

 

 

 

  • Premenstrual depression

 

 

 

  • Premenstrual irritability

 

 

 

  • Premenstrual anxiety

 

 

 

  • Premenstrual bloating

 

 

 

  • Premenstrual fluid retention

 

 

 

  • Other premenstrual symptoms (please specify)

 

 

 

 

11.

PAST MEDICAL HISTORY FOR BOTH MEN AND WOMEN: Have you ever been diagnosed with any of the following?

 

(Check  what applies to you.)

 

Hypothyroidism (low thyroid).

 

Mitral valve prolapse

 

Goiter (enlarged thyroid)

 

Irritable bowel syndrome

 

High cholesterol

 

Gallstones

 

High triglycerides

 

Alcoholism

 

Diabetes

 

Drug abuse

 

Hypoglycemia

 

Endometriosis (women)

 

Fibromyalgia

 

Fibrocystic breast (women)

 

12.            Are you allergic to any medicines? ______ Yes ______No

13.            List medicines you are currently taking:  _____________________________________________

                 ____________________________________________________________________________

 

D.  ENVIRONMENTAL AND SOCIAL HISTORY (Encircle that applies):

 

1.  I smoke; I do not smoke; Smoking at home by: _________________; Have dog; cat; Gas stove; Gas dryer

2.         Tell us about your habits regarding drinking and drugs:

 

3.         Encircle exposures at work: Tobacco smoke; Dusts; Fumes; Mists; Vapors; Solvents; Gases; Asbestos

 

4. Do any of the following smells bother you:                                                                                        Yes   No

      Tobacco smoke (987.8), exhaust fumes (980.3), bleaches, detergents, soaps (989.6), ammonia, odor of new carpeting, asphalt, tar, pine odor, moth balls, insect sprays, pesticides, weed killers, fungicides, paints, varnishes, shellac, perfumes, hair sprays, cosmetics, air fresheners, gasoline products (980.3), natural gas, new cars, furniture polish, floor wax, candle odor, burning incense, rubbing alcohol (980.2), disinfectants, household cleaners, rubber, plastics, chlorinated water (987.6), newsprint, magic markers,  new fabric stores, spray cans, food odors like cooking food or frying food, alcohol, formaldehyde, cedar wood/cedar chips, smoke from wood burning or fireplace, sulfur, latex, mold/mildew odor, odors in salons and beauty parlors, potpourri, burning leaves, just about odors of any kind. (encircle the odors that bother you)

 

 

5.  Did you ever have any surgery such as tonsillectomy, adenoidectomy, tubes in the ears, sinus surgery, gall bladder, appendectomy, hysterectomy, ovaries removed, breast operations, hernia (encircle that applies)?  Other: _______________________________________________________________________________

 

E.         Family History:

 

1.         Tell us if you have any health problems in your family:  Allergies, Asthma, Sinus, Hay fever, Headaches, Fatigue, Arthritis, High blood pressure, Heart disease, Diabetes, Breast cancer, Other cancer, Low Thyroid (Encircle that applies)

Other: __________________________________________________________________________________

 

USE THIS SPACE FOR ADDITIONAL INFORMATION

 

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