Some Patients Have Chemical Sensitivities. Please Do Not Wear Perfumes or Fragrant Products to the Office.
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- Octavia Alexander
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1 Some Patients Have Chemical Sensitivities. Please Do Not Wear Perfumes or Fragrant Products to the Office. Date: Patient Name: Date of Birth: Age: Sex: M F Are you: Married Single Divorced Widowed Separated How did you hear about our center? When did you have your last health care visit? What was the reason? Please list, in order of importance, your health problems: Family History Y = yes N = no P = past Has any family member had the following: If yes, please identify family member: Anemia Y N P Asthma Y N P Cancer Y N P Diabetes Y N P Epilepsy Y N P Glaucoma Y N P Heart Disease Y N P High Blood Pressure Y N P Kidney Disease Y N P Mental Illness Y N P Pneumonia Y N P Stroke Y N P Tuberculosis Y N P Venereal Disease Y N P Were any of these a cause of death? If so, which family member and at what age? Immunizations Polio Y N Diphtheria Y N Rubella Y N Measles/Mumps Y N Pertussis Y N Hepatitis B Y N Pneumonia Y N Small Pox Y N Anthrax Y N Tetanus Y N Date of last tetanus shot: 1
2 Childhood Illnesses Scarlet Fever Y N Diphtheria Y N Rheumatic Fever Y N Mumps Y N Measles Y N German Measles Y N Allergies What are you allergic to? What foods? Environmental Allergies? Have you ever been hospitalized? Y N If yes, when and for what reason? Have you had any surgeries? Y N If yes, when and for what reason? Current Medications Appetite Suppressants Y N Laxatives Y N Tobacco Y N Antacids Y N Pain Relievers Y N Tranquilizers Y N Birth Control Pills Y N Sleeping Pills Y N Thyroid Y N Cortisone Y N Please list any prescription medications, over-the-counter medicines, vitamins or other supplements you are currently taking: Environmental Have you often had to lower the regular dose of prescription, over-the-counter medication or herbal supplements because you were too sensitive to normal doses? Y N P Do you avoid caffeine in the afternoon or all together because it can keep you up at night? Y N P Have you ever experienced adverse reactions to medications? If so, what happened? Do you smell odors when others can t? What kind of odors? Do you have a sudden onset of symptoms (headaches, skin rashes, nausea, fatigue, shortness of breath, etc.) on exposure to chemicals, mold, dust, pollens, or other environmental allergens? What symptoms? Please list all the chemicals that you have adverse reactions to: Skin Acne Y N P Boils Y N P Color Changes Y N P Eczema Y N P Hives Y N P Itching Y N P Rash Y N P Moles Y N P Lumps Y N P Scaling Y N P Head Hair loss Y N P Headaches Y N P Head Injury Y N P Skull fracture Y N P 2
3 Eyes Eye Pain Y N P Cataracts Y N P Double vision Y N P Dryness Y N P Vision aids Y N P Glaucoma Y N P Impaired vision Y N P Tearing Y N P Ears Discharge Y N P Earaches Y N P Dizziness Y N P Impaired hearing Y N P Ringing Y N P Trauma to ear Y N P Nose & Sinuses Frequent Colds Y N P Hay fever Y N P Nose Bleeds Y N P Sinus pain Y N P Stuffiness Y N P Persistent running Y N P Trauma Y N P Polyps Y N P Mouth & Throat Bleeding gums Y N P Difficulty swallowing Y N P Cavities Y N P Frequent sore throat Y N P Hoarseness Y N P Sore tongue Y N P Ulcerations Y N P Difficulty speaking Y N P Neck Goiter Y N P Lumps Y N P Pain or Stiffness Y N P Swollen Glands Y N P Trauma to Neck Y N P Thyroid Medication Y N P Respiratory Asthma Y N P Bronchitis Y N P Cough Y N P Emphysema Y N P Pneumonia Y N P Difficulty Breathing Y N P Pleurisy Y N P Pain with Breathing Y N P Sputum Y N P Shortness of Breath Y N P Tuberculosis Y N P with lying down Y N P Wheezing Y N P with exertion Y N P Blood in Sputum Y N P at night Y N P Cardiovascular Angina Y N P Chest Pain Y N P High blood pressure Y N P Dizziness Y N P Heart disease Y N P Murmur Y N P Palpitations/flutter Y N P Leg pain with walking Y N P Rheumatic fever Y N P Ankle swelling Y N P Gastrointestinal Belching Y N P Blood in stool Y N P Change in appetite Y N P Change in thirst Y N P Gall bladder disease Y N P Heartburn Y N P Gas/Bloating Y N P Hemorrhoids Y N P 3
4 Liver disease Y N P Jaundice/yellow skin Y N P Vomiting Y N P Bowel Movements: Ulcers Y N P How often? Is this a change? Y N Urinary Frequent infections Y N P Frequency at night Y N P Increased frequency Y N P Unable to hold urine Y N P Kidney stones Y N P Kidney Pain Y N P Pain with urination Y N P Urethral discharge Y N P Endocrine/Blood Anemia Y N P Excessive thirst Y N P Easy to bleed/bruise Y N P Heat/cold intolerance Y N P Excessive hunger Y N P Low energy/fatigue Y N P Female Reproductive System Age menses began: Birth Control Y N P Average number of days: what type? Length of cycle: Number of pregnancies: Are cycles regular? Y N P Number of live births: Do you have: Number of miscarriages: Painful menses Y N P Number of abortions: Pain with intercourse Y N P Difficulty conceiving Y N P Excessive flow Y N P Menopause symptoms Y N P PMS Y N P History of venereal disease Y N P Sexual difficulties Y N P Are you sexually active Y N P Breasts Do you do self exams Y N P Nipple discharge Y N P Lumps Y N P Skin discoloration Y N P Breast Pain Y N P Male Reproductive System Hernia Y N P Are you sexually active Y N P Testicular pain Y N P Sexual difficulties Y N P Testicular masses Y N P Prostate disease/pain Y N P Discharges or sores Y N P Venereal disease Y N P Musculoskeletal Joint pain/stiffness Y N P Broken bones Y N P Swelling of joints Y N P Muscle cramps Y N P Arthritis Y N P Weakness Y N P Peripheral Vascular Cold hands/feet Y N P Varicose veins Y N P Deep leg pain Y N P Spider veins Y N P Numbness hands/feet Y N P Thrombophlebitis Y N P Neurological 4
5 Dizziness Y N P Numbness/tingling Y N P Fainting Y N P Memory loss Y N P Seizures Y N P Paralysis Y N P Mental/Emotional Anxiety/nervousness Y N P Excessive fears Y N P Depression Y N P Mood swings Y N P Excessive anger Y N P Tension/stress Y N P Habits Do you wake rested Y N P What are your main hobbies and interests? Sleep Well Y N P Average hours of sleep: Enjoy your work Y N P What forms of exercise do you get? Watch television Y N P How many hours/day: Work at a computer Y N P Exercise how often? How many hours/day: Read Y N P Have you been treated for: How many hours/day: alcohol dependence Y N P Take vacations Y N P drug dependence Y N P Do you use: Recreational drugs Y N P Alcoholic beverages Y N P Infants and Children Does your child: Sleep through the night Y N P Eat well Y N P Frequent sore throats Y N P Frequent earaches Y N P Constipation Y N P Diarrhea Y N P Hyperactive Y N P Colic Y N P Constant runny nose Y N P Lethargic Y N P Abnormal weight gain/loss Y N P Irritable Y N P Behavioral problems Y N P Skin rashes Y N P Reaction to vaccines Y N P 5
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