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