o+oriental Medicine Questionnaire
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- Ashley O’Neal’
- 7 years ago
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1 o+oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Emergency Contact: Occupation: Height: Weight: Name of your Physician Who referred you to this office? 1.What brought you here today? 2. When did you first notice any problems related to what brought you here today and what symptoms did you notice? 3. What happened since you first noticed any symptoms and up to today? 4. What previous medical workups, diagnosis and treatment have you had for this problem? How have these been helpful or unhelpful? 5. Please list any allergies to drugs or medications: 6. What medications or supplements are you currently taking: Medication Dose How long have you been taking it
2 7. Other illnesses, surgeries, injuries Illnesses Year Illness Treatment/ medications Outcome Surgeries Year Surgery Outcome Injuries / trauma Year Injury / Trauma Treatment Outcome 8. Family history Allergies Diabetes Emotional Difficulties Glaucoma Heart Problems Stroke Cancer Seizure Disorders Thyroid Problems Tuberculosis Hypertension/ High BP Please check any conditions or symptoms that you presently have or have had in the past Cough Cough with blood Shortness of breath Bronchitis Seasonal allergies Chronic colds Pneumonia Sputum/phlegm Asthma Lack of perspiration Excessive perspiration Nasal or sinus congestion Sinus infections Loss of smell Irregular heartbeat Poor circulation Dizziness Palpitations Fainting spells Indigestion Nose bleeds Nasal polyps Chest pains Heart attack Low blood pressure * High blood pressure * treatment Abdominal cramping
3 Nausea Vomiting Vomiting with blood Gas Bloating Belching Acid regurgitation Poor appetite Excessive appetite Frequent urination Excessive urination Nighttime urination Unable to hold urine Kidney stones Bladder infections Diarrhea Constipation * Laxative use * Product Alternating diarrhea and constipation Rectal pain Hemorrhoids Blood in stool Bowel movements every days number of bowel movements / day Burning on urination Difficulty urinating Painful urination Blood in urine Sexually transmitted diseases Muscle pain Muscle weakness Muscle spasms Back pain (lower) Back pain (middle) Back pain (upper) Pain goes down the legs Wear glasses Blurred vision Double vision Cataracts Glaucoma Eyes feel swollen Pressure in the eye Eye pain Hearing difficulties Ringing in the ears Ear pain Sore throats Mouth dryness * Joint pain * Where Neck pain Knee pain * Numbness * Where Eye tiredness / strain Seeing spots Sensitivity to light Eye dryness Eye redness Eye itchiness Eye tearing Loss of balance Ear infections Sore gums Bleeding gums
4 Bad taste in the mouth Bad breath Mouth sores / ulcerations Sore tongue Numbness in the tongue Grinding teeth Changes in the skin color Dandruff Skin bruising Eczema Skin rashes Psoriasis Skin acne Skin ulcerations Body hair changes Sudden weight loss Diabetes Anxiety Depression Irritability Hot tempered Stress Sudden weight gain Thyroid disorder Problems with alcohol or drug use Psychological crisis Psychoactive medications if yes which ones Emotional difficulties Fevers Chills Cold intolerance General chilliness Cold hands / feet Heat intolerance General warmth Fatigue Anemia Poor memory Seizures Concussion Headache Shaking / tremors Cysts / tumors Edema / water detention Night sweating Insomnia Nightmares
5 Smoking: How much per day? Alcohol: How much per day? Nutrition What do you typically eat for the following: Breakfast: Lunch: Dinner: Exercise What is your daily activity level related to your occupation: Sedentary i.e mostly sitting somewhat active moderately active very active (moving around or up most of the time) heavy duty (lifting, moving thingd etc.) What kind of physical activity level (exercise, sports) do you participate in. How often per week? How long each time? Miscellaneous: How much water do you drink per day? How many caffeine containing products (coffee, tea, carbonated pop) do you drink per day? Snacks : Male patients: Please fill out the following section Please check any conditions or symptoms that you presently have or had in the past Prostate enlargement Prostatitis Premature ejaculation Impotence
6 Female patients Please fill the following section Pregnancy: Are you presently pregnant? Y N Not sure Please list history of pregnancy, note if full term (FT), premature (P), miscarriage (MC), abortions (A), whether vaginal (V) or Cesarean section (C). Note any difficulties you experienced during the pregnancy and/or after delivery (for example morning sickness, edema, prolonged bleeding after delivery, gestational diabetes, high blood pressure, fever postpartum etc.) Year Menstruation Age of onset Last Menstrual Period (first day of) Date of last Pap exam / / Result Length between periods Regularity: regular irregular usually early usually late varies between by days by days being early or late How many days of menstrual flow do you usually have?: Flow is: even uneven heavy light Color is pale pink light red red deep red purplish brown Consistency is : thin thick clotted Discomfort with period: lower abdominal distention before during after menstruation lower back soreness before during after menstruation cramping before during after menstruation Other Premenstrual Syndrome (PMS) irritability bloating mood swings breast tenderness other Vaginal Discharge No Yes If yes, color and amount: Menopause: Age of onset Any difficulties / symptoms? Uterine bleeding (not related to periods) Color amount comes on suddenly all the time
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