DRONYK CLINIC. Adult Health History Summary

Transcription

1 DRONYK CLINIC Adult Health History Summary Name Age Date of Birth Blood Type Address City Postal Code Phone (home) (work) Occupation Emergency Contact Phone # How did you hear about our clinic? Last physician or health practitioner seen? When? What was the reason for that visit? Current Health Problems What is your main reason for coming in today? List in order of important any other health problems that are troubling you: 1) date of onset 2) date of onset 3) date of onset 4) date of onset Other problems: How long has your main problem been troubling you? Has your main problem been getting better, worse, unchanged? What kind of treatment have you received/are you receiving for your main problem, and from whom? Have you ever seen a naturopathic doctor, chiropractor, acupuncturist or other natural health practitioner for your current problem ( Y/ N ) or for any other problem ( Y / N )?

2 Your Health History The general state of your health is (please check): Excellent Good Average Fair Poor How would you rate your average energy level on a scale from 1-10 (10 being highest)? What is your approximate: height weight weight one year ago Please list the 5 most significant stressful events or ongoing stressors/worries in your life: 1) date (if applicable) 2) date (if applicable) 3) date (if applicable) 4) date (if applicable) 5) date (if applicable) Are you currently working with a professional counselor, psychologist, social worker, pastor or any other therapist? Have you in the past? If so, when? Are you currently working with a medical doctor? If so, whom? Please indicate any of the following that you have had or currently have with an N (now) or a P (past): Asthma Allergies Alcoholism Anemia Arthritis Blood Pressure Abnormalities Bronchitis Cancer Chronic Fatigue Carpal Tunnel Syndrome Circulatory Problems Colitis Dental Problems Depression Diabetes Drug Addiction Eating Disorder Epilepsy Emphysema Eye/Ear/Nose Problems Heart Disease Chronic Infection Irritable bowel syndrome Kidney/bladder disease Learning disabilities Mental Illness Liver Disease Gallstones Migraine headaches Sinus Problems Stroke Thyroid trouble Obesity Pneumonia Sexually-transmitted disease Skin problems Tuberculosis Ulcer Urinary tract infection Varicose Veins

3 Environmental Sensitivities Heart Burn Insomnia Fibromyalgia Food intolerance Glaucoma Gout Other Abuse (physical/mental/emotional/sexual) Are there any of these from which you feel you have never fully recovered? Do you have any allergies? (drugs, foods, plants, animals, chemicals, etc.) Have you had any of the following childhood illnesses (please check applicable): Measles Mumps Chickenpox Whooping Cough Polio Mononucleosis Diptheria Rheumatic Fever Scarlet Fever Other Which (if any) of the following do you currently use? Provide approximate frequency if applicable (sometimes, often, seldom): Alcohol Hormones Cortisone Sedatives Tobacco Coffee Laxatives Antacids Recreational Drugs Vitamins/Homeopathic remedies Other medications Digestion Do you have any problems with gas, bloating or excessive fullness? How long have you had this problem? How often do you have a bowel movement? Do you ever have any blood, mucus, or undigested foods in your stool?

4 Do you ever have any problems with constipation? If so, how often? Do you ever have heartburn/acid reflux? Do you have disagreeable breath? Have you travelled outside of Canada in the last 5 years? Have you ever had a parasitic infection? Female Reproduction What age were you when you first got your period? Have your periods ever stopped? If yes, what age and for how long? Are your cycles regular? Your period cycle is, days long and your period is present for (approx.) days. How heavy are your periods? What colour is the blood? Are there any clots? Do you have any spotting? Do you have cramps or pain associated with your periods? Do you have any pre-menstrual symptoms? (water retention, breast tenderness, irritability, depression, headaches, mood swings, crying, acne, bloating, cravings, etc. ) Please describe: Have you been pregnant? Had an abortion? Miscarried? Total Number of Pregnancies Do you or have you had any difficulties becoming pregnant? Do you get yearly PAP smears? Any abnormal results? Do you do regular breast self-examinations? Any lumps? Are you currently sexually active? How is your sex drive? What type (if any) of birth control do you use? Male Reproduction How often to you urinate? Do you need to void through the night? Has this increased at all over the past 2 years? Do you have any problems with impotency? Any sores on your genitals? Have you ever had any prostate problems? Have you ever had your prostate examined? If so, when? Are you sexually active? Any problems related to your sex drive? Personal Habits/Lifestyle What do you enjoy most in your life? What are your main interests or hobbies? What do you worry about most?

5 Do you have a spiritual practice? Do you exercise? If yes, what type and frequency? Do you have any sleep problems? How many hours of sleep would you say you get per night, on average? Do you wake feeling refreshed? Do you awaken through the night? Do you sweat at night? How many hours of sleep do you think you need? Do you enjoy your work? Do you take vacations? Are you in a happy and supportive relationship? How often do you get colds, flues, and sore throats? Are you exposed to second-hand smoke on a regular basis? What kind of water do you drink (ie. bottled, distilled, tap, filtered) and how much of it do you drink per day (on average)? Family History Do you have any blood relatives who have or have had any of the following conditions? Check yes if applicable and provide more information if possible. Allergies Arthritis Asthma Cancer Diabetes Anemia Depression Skin Disease Heart Disease V Genetic Disorder Blood Pressure Abnormalities Stroke Ulcers Cataracts Thyroid Problems Hypoglycemia Seizures Sickle Cells Mental illness Venereal disease Do you have anything else you would like to comment on or discuss with the doctor? _