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AUTHORIZATION FOR RELEASE OF MED
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Referred by:
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Name of primary care physician
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Address
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Phone #
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Marital Status:
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Occupation
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Hours per week
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Retired
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Nature of Business
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List Problem
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Date of Onset
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Severity/Frequency
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Treatment Approach
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Success
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List problems
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Date of Onset
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Severity/Frequency
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Treatment Approach
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Success
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List of problems
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Date of Onset
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Severity/Frequency
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Treatment Approach
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Success
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List of problems
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Date of Onset
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Severity/Frequency
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Treatment Approach
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Success
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List of problems
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Date of Onset
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Severity/Frequency
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Treatment Approach
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Success
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Diagnosis given for your concern
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last time that you felt well
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What seems to trigger symptoms
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worsen your symptoms
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make you feel better
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physician seen for the problem
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Time lost from work/school
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Ever experienced the following
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Experienced Anemia
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WHEN /ONSET
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Comments
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Arthritis
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WHEN /ONSET
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Comments
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Asthma
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WHEN /ONSET
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Comments
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Bronchitis
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WHEN /ONSET
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Comments
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Cancer
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When/Onset
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Comments
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Chicken Pox
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When/Onset
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Comments
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Chronic fatigue syndrome
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When/Onset
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Comments
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Crohn’s Dis/Ulcerative Colitis
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When/Onset
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Comments
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Diabetes
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When/Onset
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Comments
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Emphysema
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When/Onset
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Comments
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Epilepsy, convulsions/ seizures
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When/Onset
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Comments
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Gallstones
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When/Onset
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Comments
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German Measles
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When/Onset
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Comments
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Gout
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When/Onset
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Comments
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Heart Attack, Angina
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When/Onset
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Comments
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Heart Failure
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When/Onset
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Comments
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Hepatitis
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When/onset
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Comments
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Herpes Lesions/Shingles
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When/Onset
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Comments
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High blood fats
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When/Onset
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Comments
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High blood pressure
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When/Onset
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Comments
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Irritable bowel
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When/Onset
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Comments
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Kidney stones
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When/Onset
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Comments
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Measles
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When/Onset
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Comments
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Mononucleosis
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When/Onset
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Comments
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Mumps
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When/Onset
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Comments
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Pneumonia
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When/Onset
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Comments
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Rheumatic Fever
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When/Onset
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Comments
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Sinusitis
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When/Onset
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Comments
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Sleep Apnea
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When/Onset
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Comments
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Stroke
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When/Onset
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Comments
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Thyroid disease
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When/Onset
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Comments
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Whooping Cough
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When/Onset
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comments
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Describe other illness
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When/Onset
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Comments
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Describe other illness
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when/onset
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Comments
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INJURIES
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Back injury
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When/Onset
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Comments
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Broken bones or fractures
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When/Onset
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Comments
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Head injury
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When/Onset
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Comments
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Neck injury
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When/Onset
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Comment
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Describe other injuries
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When/Onset
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Comment
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Describe other injuries
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When/Onset
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Comment
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DIAGNOSTIC STUDIES
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Blood Tests
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When
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Comments
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Bone Density Test
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When
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Comments
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Bone Scan
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When
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Comments
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Carotid Artery Ultrasound
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When
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Comments
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CAT Scan
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If yes, Type
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When
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Comments
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Colonoscopy
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When
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Comments
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EKG
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When
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Comments
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Liver Scan
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When
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Comments
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Mammogram
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When
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Comments
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Neck X-Ray
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When
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Comments
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MRI
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When
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Comments
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X-Ray
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If yes, Type
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When
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Comments
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Other diagnostic test done
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When
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Comments
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Other diagnostic test
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When
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Comments
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SURGERIES
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Appendectomy
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When
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Comments
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Dental Surgery
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When
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Comments
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Gall Bladder
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When
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Comments
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Hernia
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When
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Comments
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Hysterectomy
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When
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Comments
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Tonsillectomy
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When
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Comments
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Tubes in Ears
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When
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Comments
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Other surgeries describe
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When
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Comments
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Other surgeries describe
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When
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Comments
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HOSPITALIZATIONS
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WHERE HOSPITALIZED
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When
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Reason
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WHERE HOSPITALIZED
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When
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Reason
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WHERE HOSPITALIZED
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When
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Reason
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WHERE HOSPITALIZED
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When
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Reason
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WHERE HOSPITALIZED
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When
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Reason
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MEDICATIONS
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How often you take antibiotic
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Infancy/Childhood
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Comments
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Teen
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Comments
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Adulthood
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Comments
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Often you take oral steroid
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Infancy/Childhood
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Comments
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Teen
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Comments
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Adulthood
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Comments
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List all medications
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Medication Name
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Date started
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Date stopped
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Dosage
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Medication Name
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Date started
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Date stopped
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Dosage
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Medication Name
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Date started
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Date stopped
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Dosage
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Medication Name
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Date started
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Date stopped
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Dosage
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List all vitamins/supplements
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Type
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Date started
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Date stopped
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Dosage
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Type
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Date started
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Date stopped
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Dosage
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Type
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Date started
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Date stopped
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Dosage
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Type
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Date started
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Date stopped
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Dosage
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CHILDHOOD HISTORY
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Where you a full term baby?
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Comments
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A premature birth?
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Comments
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Breast fed?
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Comments
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Bottle fed?
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Comments
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When pregnant, did ur mother
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Smoke tobacco?
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Comments
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Use recreational drugs?
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Comments
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Drink alcohol?
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Comments
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Use estrogen?
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Comments
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Prescribed/non prescribed med
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Comments
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IMMUNIZATION HISTORY
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Smallpox
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Comments
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Tetanus
|
Comments
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Diphtheria
|
Comments
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Pertussis
|
Comments
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Polio (oral)
|
Comments
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Polio (injection)
|
Comments
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Mumps
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Comments
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Measles
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Comments
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Rubella (German Measles)
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Comments
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Typhoid
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Comments
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Cholera
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Comments
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CHILDHOOD DIET
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Was your childhood diet high in:
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Sugar?
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Comments
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Soda?
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Comments
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Fast food, pre-packaged foods
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Comments
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Milk, cheeses,dairy product
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Comments
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Meat, vegetables, & potato diet
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Comments
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Vegetarian diet?
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Comments
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Diet high in white breads?
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Comments
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avoid food coz they gave symptom
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If yes, Please explain
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CHILDHOOD ILLNESSES
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Attention Deficient Disorder
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If yes, age
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Asthma
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If yes, age
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Bronchitis
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If yes, age
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Chicken Pox
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If yes, age
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Colic
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If yes, age
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Congenital problems
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If yes, age
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Ear infections
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If yes, age
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Fever blisters
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If yes, age
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Frequent colds or flu
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If yes, age
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Frequent headaches
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If yes, age
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Hyperactivity
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If yes, age
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Jaundice
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If yes, age
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Mumps
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If yes, age
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Pneumonia
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If yes, age
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Seasonal allergies
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If yes, age
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Skin disorders
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If yes, age
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Strep infections
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If yes, age
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Tonsillitis
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If yes, age
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Upset stomach, digestive problem
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If yes, age
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Whooping cough
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If yes, age
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Measles
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If yes, age
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Other illness
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Age of onset
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Other illness
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Age of onset
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As a child did you
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Have a high absence from school
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If yes, why?
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Exposure to smoke in your house
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Experience abuse
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Have alcoholic parents
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FEMALE MEDICAL HISTORY
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OBSTETRICS HISTORY
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Number of Pregnancies
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Miscarriage
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# of miscarriages
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Post partum depression
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# of occurrence
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Caesarean
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# of occurrence
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Abortion
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# of occurrence
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Toxemia
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# of occurrence
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Vaginal deliveries
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# of occurrence
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# Living Children
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Gestational diabetes
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# of occurrence
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GYNECOLOGICAL HISTORY
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Age at first menses
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Frequency
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Length
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Painful
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Clotting
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Date of last menstrual period
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Do you use contraception
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If yes which form- Non-hormonal
• • •
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Other form
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Hormonal Form
• • •
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Other form
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Type of hormonal birth control
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for how long
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Breast tenderness 2nd half cycle
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Other symptoms you feel
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Are you menopausal
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If yes, age of menopause
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take hormone replacement
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If yes, what type
• • •
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Any other type
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How long
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DIAGNOSTIC TESTING
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Last PAP test
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Result
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Last Mammogram
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Breast biopsy date
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Date of last bone densitiy
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Result
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FAMILY HEALTH HISTORY
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Father age (if still living)
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Father age at death(if deceased)
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Current or past history
• • •
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Any other history
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Mother age (if still living)
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Mother age at death(if deceased)
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Current or past history
• • •
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Any other history
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Brother(s) age (if still living)
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Brother(s) age at death(if decea
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Current or past history
• • •
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Any other history
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Sister(s) age(if still living)
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Sister(s) age at death(if deceas
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Current or past history
• • •
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Any other history
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Children age (if still living)
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Children age at death(if decease
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Current or past history
• • •
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Any other history
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Maternal Grandmom age(if alive)
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Maternal Grandmom age at death
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Current or past history
• • •
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Any other history
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Maternal grandfathers age(if ali
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Maternal grandfathers age death
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Current or past history
• • •
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Any other history
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Paternal grandmom age(if alive)
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Paternal grandmom age at death
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Current or past history
• • •
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Any other history
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Paternal granddad age (if alive)
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Paternal granddad at death
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Current or past history
• • •
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Any other history
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REVIEW OF SYMPTOMS
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GENERAL
• • •
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HEAD:
• • •
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SKIN:
• • •
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Is your skin sensitive to:
• • •
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EYES:
• • •
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EARS:
• • •
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NOSE/SINUSES
• • •
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Seasons make symptom worse
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If yes, is it worse in the:
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CIRCULATION/RESPIRATION:
• • •
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If heart attack, when
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MOUTH:
• • •
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THROAT:
• • •
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NECK:
• • •
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GASTROINTESTINAL
• • •
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WOMEN’S HISTORY (for women only)
• • •
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MEN’S HISTORY (for men only)
• • •
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times urination at night
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Have you had a PSA done
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PSA Level:
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KIDNEY/URINARY TRACT:
• • •
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WOMEN’S HISTORY (for women only)
• • •
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JOINT/MUSCLES/TENDONS
• • •
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EMOTIONAL:
• • •
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PAIN ASSESSMENT
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Are you currently in pain?
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Source of pain due to injury
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If yes, describe injury and date
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If no, how long have u experince
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What attributed to the pain
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Area of pain
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Pain scale
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Area 2 of pain
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Pain scale
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Area 3 of pain
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Pain scale
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Area 4 of pain
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Pain scale
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Human Body
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DENTAL HISTORY
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Problem with sore gums
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Ringing in the ears
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Have TMJ problems
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Metallic taste in mouth
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Problems with bad breath
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Previously/currently wear braces
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Problems chewing
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Floss regularly
|
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amalgam dental fillings
|
If yes, how many
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RCV fillings as a child
|
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|
List below dental work
|
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Type of dental work
|
Age
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Describe health problems
|
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Type of dental work
|
Age
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Describe health problems
|
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Type of dental work
|
Age
|
|
Describe health problems
|
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Type of dental work
|
Age
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Describe health problems
|
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Type of dental work
|
Age
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Describe health problems
|
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NUTRITIONAL HISTORY
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Change in diet due to health
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FOOD DIARY
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Usual Breakfast
• • •
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Other breakfast
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Usual Lunch
• • •
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Other lunch
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Usual Dinner
• • •
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Other dinner
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How much you consume each week
|
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Candy
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Cheese
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Chocolate
|
Cups of coffee containing caffei
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Cups of decaffeinated coffee/tea
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Cups of hot chocolate
|
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Cups of tea containing caffeine
|
Diet soda
|
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Ice cream
|
Salty foods
|
|
Slices of white bread
|
Soda with caffeine
|
|
Soda without caffeine
|
|
|
Follow special diet program
|
|
|
If yes, what type
• • •
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Other type
|
|
anything special about your diet
|
symptoms after eating
|
|
symptoms associated with food
|
If yes, name food and supplement
|
|
Delayed symptoms after eating
|
|
|
feel worse when you eat a lot of
• • •
|
Other
|
|
feel better when you eat a lot
• • •
|
Other
|
|
Skipping meal affect symptom
|
|
|
Food that you craved for
|
If yes, what foods
|
|
aversion to certain foods
|
If yes, what foods
|
|
Bowel movement chart
|
|
|
Frequency
|
Color
|
|
Consistency
• • •
|
Intestinal gas:
• • •
|
|
LIFESTYLE HISTORY
|
|
|
TOBACCO HISTORY
|
|
|
Have you ever used tobacco
|
If yes, what type
• • •
|
|
How much
|
Number of years?
|
|
If not a current user, year quit
|
Attempts to quit
|
|
Exposed to 2nd hand smoke
|
If yes, please explain
|
|
ALCOHOL INTAKE
|
|
|
Have you ever used alcohol
|
If yes, how often do u now drink
|
|
notice a tolerance to alcohol
|
|
|
Had problems with alcohol
|
If yes, indicate time period
|
|
OTHER SUBSTANCES
|
|
|
Currently/have used drugs
|
If yes, what type(s) and method
|
|
Exposed to toxic metal
|
If yes, indicate which
• • •
|
|
SLEEP & REST HISTORY
|
|
|
Average number of hours u sleep
|
Have trouble falling asleep
|
|
Feel rested upon wakening
|
Have problems with insomnia
|
|
Snore?
|
Use sleeping aids
|
|
EXERCISE HISTORY
|
|
|
Do you exercise regularly
|
Type of exercise
• • •
|
|
Other exercise
|
Times/week
|
|
Length of session
|
problems limit your activity
|
|
SOCIAL HISTORY
|
|
|
Are you overall happy
|
Easily handle stress
|
|
stress reducing quality of life
|
|
|
Know source of your stress
|
If yes, what u believe it to be
|
|
ever contemplated suicide
|
If yes, how often
|
|
When was the last time
|
|
|
sought help through counseling
|
If yes, what type
|
|
Did it help
|
|
|
How well have things been going
|
|
|
At school
|
In your job
|
|
In your social life
|
With close friends
|
|
With sex
|
With your attitude
|
|
With your boyfriend/girlfriend
|
With your children
|
|
With your parents
|
With your spouse
|
|
Which provides emotional support
• • •
|
Other
|
|
Involved in abusive relation
|
Have you ever been abused
|
|
feel safe growing up
|
Alcohol abuse present at home
|
|
Abuse present in relation now
|
Religion for you and ur family
|
|
Do you practice meditation
|
If yes, how often?
|
|
Check all that apply:
• • •
|
Other
|
|
Hobbies and leisure activities:
|
Anything else you want to discus
|
|
READINESS ASSESSMENT
|
|
|
Significantly modify your diet
|
nutritional supplement daily
|
|
Record everything u eat out
|
Modify your lifestyle
|
|
Modify your lifestyle
|
Practice relaxation techniques
|
|
Engage in regular exercise
|
lab tests to asses progress
|
|
Comments
|
|
|
|
|
|
Detoxification Questionnaire
|
|
|
Gastrointestinal
|
|
|
Belching or gas
|
Heartburn or acid reflux
|
|
Bloating or abdominal discomfort
|
Bad breath (halitosis)
|
|
Aggravated by certain foods
|
Diarrhea, chronic
|
|
Undigested food in stool
|
Constipation
|
|
Nausea or vomiting
|
Fewer than 1 bowel movement day
|
|
Stools are loose and unformed
|
|
|
Total
|
|
|
Liver
|
|
|
Wine makes you sick
|
Easily intoxicated by alcohol
|
|
Hangovers after drinking alcohol
|
Sensitive to chemicals
|
|
Sensitive to tobacco smoke
|
Hemorrhoids or varicose veins
|
|
Bothered by aspartame
|
Chronic fatigue or Fibromyalgia
|
|
Feeling wired after coffee
|
Feet have a strong odor
|
|
Sweat has a strong odor
|
|
|
Total
|
|
|
Skin
|
|
|
Experience hives/cysts/boils
|
Cold sores, fever blisters
|
|
Dry flaky skin and/or dandruff
|
Fragile skin, easily chaffed
|
|
Acne
|
Itchy skin / dermatitis
|
|
Dull colored skin
|
Pale complexion
|
|
Skin has a sour
|
|
|
Total
|
|
|
Eyes
|
|
|
Dark circles around the eyes
|
Puffy eyelids
|
|
Bags under the eyes
|
Bloodshot or reddened eyes
|
|
Whites of eyes are yellowed
|
Inflamed eyelids
|
|
Eyes are water and/or itchy
|
Blurred or tunnel vision
|
|
Total
|
|
|
Nails
|
|
|
Ridged nails
|
Splitting nails
|
|
White spots on nails
|
Crumbling nails
|
|
Total
|
|
|
Ears
|
|
|
Ear infections
|
Ear drainage or discharge
|
|
Itchy ears
|
Ringing in the ears
|
|
Total
|
|
|
Nose
|
|
|
Stuffy nose
|
Airborne allergies
|
|
Sinus congestion
|
Runny or drippy nose
|
|
Total
|
|
|
Head
|
|
|
Tension headaches
|
Splitting type headache
|
|
Dizziness
|
Faintness
|
|
Total
|
|
|
Mouth and Throat
|
|
|
Coated tongue
|
Swollen tongue
|
|
Hoarseness
|
Difficulty swallowing
|
|
Lump in throat
|
Dry mouth, eyes and / or nose
|
|
Gag easily
|
Mouth ulcers or canker sores
|
|
Total
|
|
|
Heart/Lungs
|
|
|
Asthma
|
Wheezing or difficulty breathing
|
|
Shortness of breath
|
Chest congestion
|
|
Heart races, rapid heartbeat
|
Fast pulse at rest
|
|
Flush or blush easily
|
|
