|
Last time had blood work performed
|
With which physician?
|
|
Have primary care physician
|
If yes, please name.
|
|
Family History
|
Family History
|
|
Father
|
|
|
Father's age. (If deceased, type 'deceased')
|
If deceased, reason for death.
|
|
Disease(s) on father's side
• • •
|
Cancer Type( Father)
|
|
Mother
|
|
|
Mother's age (if deceased, type 'deceased')
|
If deceased, reason for death?
|
|
Disease(s) on mother's side?
• • •
|
Cancer type(Mother)
|
|
Siblings
|
|
|
Siblings age if living
|
Reason for Death(Siblings)
|
|
Cancer- Type(siblings)
|
Disease siblings
• • •
|
|
Grandparents
|
|
|
Grandparents age if living
|
Reason for Death(Grandparents)
|
|
Cancer-Type grandparents
|
Disease Grandparents
• • •
|
|
Spouse
|
|
|
Spouse age if living
|
Reason for Death(Spouse)
|
|
If cancer, please state which kind.
|
Disease(s)
• • •
|
|
Children
|
|
|
Children's age if living
|
If deceased, please state reason.
|
|
If cancer, please state which kind.
|
Disease Children
• • •
|
|
Surgeries
|
|
|
List surgeries
|
Date
|
|
List surgeries
|
Date
|
|
List surgeries
|
Date
|
|
List surgeries
|
Date
|
|
List surgeries
|
Date
|
|
Hospitalizations
|
|
|
List hospitalization
|
Date
|
|
List hospitalization
|
Date
|
|
List hospitalization
|
Date
|
|
List hospitalization
|
Date
|
|
List hospitalization
|
Date
|
|
Imaging
|
|
|
When did you have/had xrays
|
Why
|
|
When have/had MRI/CT scan
|
Why
|
|
When have/had ultrasounds
|
why
|
|
Further Information
|
|
|
When have/had Accidents
|
Why
|
|
Disease History
|
|
|
When have/had TB Test
|
Why
|
|
When have/had HCV
|
When
|
|
When have/had HIV
|
When
|
|
When have/had Last Dental Visit
|
When
|
|
When have/had Last Eye Exam
|
When
|
|
Measles
|
Chicken Pox
|
|
Mumps
|
Rubella
|
|
Tetanus
|
Whooping Cough
|
|
Hemophilus (Hib)
|
Hepatitis B
|
|
Rheumatic Fever
|
HPV
|
|
Polio
|
Small Pox
|
|
Diptheria
|
Scarlet Fever
|
|
Typhoid Fever
|
|
|
Any vaccination reaction
|
Other
|
|
Addictive Substances
|
|
|
Do you use the following?
|
|
|
Antacids
|
Steroids
|
|
Smoking
|
Packs per day & # years
|
|
Analgesics
|
Laxatives
|
|
Coffee
|
Cups per day
|
|
Soda Pop
|
Ounces per day
|
|
Alcohol
|
How often, type and how much
|
|
Any Alcohol Addiction
|
Any Alcohol Treatment
|
|
Recreational Drugs
|
Any Drug Addictions
|
|
Current Medication
|
|
|
Medications Name
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Medications Name
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Medications Name
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Medications Name
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Current Supplements
|
|
|
Supplements/vitamin/herbs
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Supplements/vitamin/herbs
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Supplements/vitamin/herbs
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Supplements/vitamin/herbs
|
Dose
|
|
When/How Often
|
What Purpose
|
|
Weight and Height
|
|
|
Review of Systems
|
|
|
Present Weight
|
Weight one year ago
|
|
Height
|
Maximum weight and when
|
|
Minimum weight as adult & when
|
Ideal Weight
|
|
Allergy Information
|
|
|
Drug allergies
|
Food allergies
|
|
Other allergies
|
Supplement allergies
|
|
Energy Level
|
|
|
Good Energy
|
Fatigue
|
|
When Fatigue becomes worst
|
If fatigue, can do work at day
|
|
Body Systems
|
|
|
Have/had the following
|
|
|
NOSE
• • •
|
HEAD
• • •
|
|
EARS
• • •
|
EYES
• • •
|
|
NECK
• • •
|
MOUTH/THROAT
• • •
|
|
CARDIOVASCULAR
• • •
|
RESPIRATORY
• • •
|
|
GASTROINTESTINAL
• • •
|
Bowel Movement # of times/day
|
|
URINARY TRACT
• • •
|
NERVOUS SYSTEM
• • •
|
|
MUSCULOSKELETAL
• • •
|
Mental/Emotional
• • •
|
|
MALE GENITALIA
• • •
|
FEMALE GENITALIA
• • •
|
|
Sexual Orientation
|
|
|
Women's Health
|
|
|
How Often Period Occurs
|
Age Period Began
|
|
Times Pregnant
|
How long period lasts
|
|
Miscarriages
|
How many births
|
|
Last Pap Smear
|
Abortions
|
|
Any abnormal paps
|
Diagnosis
|
|
Menopausal since what age
|
When was abnormal
|
|
Dexa scans result
|
Type of hormones used
|
|
List birth control/ age used
|
|
|
Lifestyle and Habits
|
|
|
Exercise
|
|
|
How often do you exercise
|
What type of exercise
|
|
For how long
|
Hobbies
|
|
Sleep
|
|
|
How long per night
|
Reason to wakeup frequently
|
|
Nightmares
|
Wake Refreshed
|
|
Must nap during the day
|
Sleep walk
|
|
Grind teeth
|
Snore
|
|
Toxin Exposure
• • •
|
Type of toxin exposure
|
|
Social Life
|
|
|
Enjoy job
|
Hours worked per week
|
|
Job Position
|
Highest Level of Education
|
|
Active spiritual practice
|
Quality of significant relations
|
|
History of sexual/physical abuse
|
If yes, by what age and whom
|
|
greatest health concern
|
How does it limit you the most
|
|
significant stressful events
|
significant stressful events
|
|
significant stressful events
|
significant stressful events
|
|
significant stressful events
|
Committed to make changes
|
|
Typical Day’s Diet
|
|
|
Breakfast
|
Lunch
|
|
Dinner
|
Snacks
|
|
Beverages
|
|
|
Only children below 18 respond
|
|
|
Name of School and Grade
|
Mother’s Name and Occupation
|
|
Father’s Name and Occupation
|
Other
|
|
Parents are
|
phone number
|
|
Regular Pediatrician name
|
|
|
Hearing Tests Normal
|
Vision Tests Normal
|
|
Speech Impediments
|
Learning Impediments
|
|
Pregnancy and Motherhood
|
|
|
Mother’s Pregnancy History
|
|
|
Age at conception
|
Did she have other children
|
|
Health During Pregnancy
|
|
|
Smoking
|
Diabetes
|
|
Coffee
|
Nausea/Vomiting
|
|
Recreational Drugs
|
Emotional Stress
|
|
Preeclampsia
|
Vaginal Birth
|
|
Traumatic Birth
|
Length of Labor
|
|
If birth was difficult,explain
|
Health of baby at birth
|
|
Health History of Child
|
|
|
Child Breastfed
|
For how long
|
|
When put on formula
|
What Formula was used
|
|
When was child put on solid food
|
When did child walk
|
|
When did child Talk
|
When did child Develop Teeth
|
|
Health history of a child
• • •
|
Bowel movements# of times per day
|
|
Urination# of times per day
|
Potty trained
|
|
Any concerns with potty training
|
Sleep (location, total hours)
|
|
|
|
|
Credit Card Details
|
|
|
Card Type
• • •
|
Card Number (include dashes)
|
|
Expiration Date (month/year)
/
|
CVV code (3 digit code on back)
|
|
Credit or Debit
|
Would you like a receipt?
|
|
Cardholder Name
|
Billing Zip Code
|
|
|
|
|
This information is correct
|
Electronic Signature (full name)
|
