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Patient Marital Status
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Patient Lives with
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Occupation
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Hours per week
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Employer Name & Address
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Any family seen here? If so, who
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What are your reasons for coming
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How did you hear about us/Clinic
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Expectations of my doctor:
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3 expectations from this visit
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Long term expectations from us?
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Present level of commitment?
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List your current healthy habits
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What do you love to do?
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Currently receiving health care?
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When and where?
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What is/was the reason?
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List your obstacles to health
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Who supports you and your health
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Family History - Health Problems
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Other relevant family history
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Birth city & state
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Birth Weight
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What is your family heritage?
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Childhood Health Problems
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Previous X-Rays and Year
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Previous Surgeries and Year
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Previous Hospitalizations/Year
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Previous CT scans and Year
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Previous EEG and Year
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Previous EKG and Year
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When is your energy the best?
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When is your energy the worst?
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Do you exercise?
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If yes, what kind and how often?
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Main interests and hobbies
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Do you have a spiritual practice
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If yes, what kind of practice?
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Do you sleep well?
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Do you awake rested?
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Do you average 8 hours nightly?
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What do you eat for breakfast?
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What do you eat for lunch?
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What do you eat for dinner?
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Snacks:
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Beverages and quantities
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Do you have a history of abuse?
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Do you feel supported?
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Do you use recreational drugs?
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Have you experienced trauma?
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Do you use alcoholic beverages?
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Have you been in drug rehab?
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Do you use tobacco?
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If yes, how many packs per day?
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If in past, # cigarettes/day?
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If in past, when did you quit?
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Do you enjoy your work?
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Take vacations?
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Spend time outside?
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Do you go on diets often?
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Do you drink coffee?
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Drink black/green tea?
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Drink soda?
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Do you eat three meals a day?
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Do you add salt to your food?
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Do you eat refined sugar?
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Do you eat out often?
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NEUROLOGICAL
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Seizures
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Muscle weakness
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Loss of memory
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Vertigo or dizziness
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Paralysis
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Numbness or tingling
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Easily stressed
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Loss of balance
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ENDOCRINE
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Hypothyroidism
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Hyperthyroidism
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Excessive thirst
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Hypoglycemia
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Fatigue
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Heat or cold intolerance
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Diabetes
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Excessive hunger
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Seasonal depression
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Difficulty exercising
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NOSE AND SINUS
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Frequent colds
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Stuffiness
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Sinus problems
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Nose bleeds
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Hayfever
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Loss of smell
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NECK
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Lumps in neck
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Goiter
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Difficulty swallowing
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Pain or stiffness in neck
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MOUTH AND THROAT
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Frequent sore throat
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Copious saliva
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Sore tongue or lips
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Hoarseness
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Jaw clicks
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Teeth grinding
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Gum problems
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Dental cavities
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IMMUNE
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Reactions to immunizations
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Chronically swollen glands
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Slow wound healing
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Chronic fatigue syndrome
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Chronic infection
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Night sweats
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EARS
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Impaired hearing
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Ringing in ears
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Dizziness
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Ear aches
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EYES
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Eye pain/strain
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Impaired vision
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Glasses or contacts
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Cataracts
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Spots in vision
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Colorblindness
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Tearing or drying
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HEAD
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Headaches
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Migraines
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TMJ or jaw problems
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Head Injury
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SKIN
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Rashes
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Acne/boils
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Change in skin color
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Lumps or bumps on skin
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Eczema or hives
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Itching
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Perpetual hair loss
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RESPIRATORY
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Cough
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Sputum
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Asthma
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Wheezing
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Bronchitis
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Coughing up blood
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Shortness of breath
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Short of breath when lying
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Pain in breathing
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Emphysema
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Tuberculosis
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BLOOD
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Anemia
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Easy bleeding or bruising
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Cold hands/feet
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Deep leg pain
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Thrombophlebitis
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Varicose veins
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GASTROINTESTINAL
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Trouble swallowing
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Change in thirst
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Change in appetite
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Nausea / Vomiting
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Ulcer
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Jaundice
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Gall bladder disease
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Liver disease
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Hemorrhoids
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Pancreatitis
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Heartburn
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Abdominal pain or cramping
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Belching or passing gas
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Constipation
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Diarrhea
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Bowel movements: how often?
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Black stools
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Blood in stool
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MENTAL/EMOTIONAL
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Treated for Emotional Problems
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Depression
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Anxiety or Nervousness
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Poor Concentration
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Mood Swings
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Considered Suicide
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Attempted Suicide
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Tension
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Memory Problems
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MUSCULOSKELETAL
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Joint Pain or Stiffness
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Arthritis
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Broken Bones
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Muscle spasms or cramps
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Weakness
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Sciatica
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URINARY
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Frequency of urination
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Inability to Hold Urine
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Pain in Urination
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Frequency at Night
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Frequent UTIs
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Kidney Stones
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FEMALE REPRODUCTIVE
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Age of first menses
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Age of last menses (if menopau.)
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Length of cycle (days)
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Duration of menses (days)
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Are your cycles regular?
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Painful menses
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Heavy or excessive flow
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PMS
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Menstrual Symptoms
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Bleeding between cycles
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Clotting
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Endometriosis
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Ovarian cysts
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Vaginal discharge
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Vaginal odor
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Date of last pap smear
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Abnormal PAP
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Cervical dysplasia
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Birth control? Type
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Sexual orientation
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Are you sexually active?
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Pain during intercourse
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Herpes
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Gonorrhea
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Chlamydia
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Syphilis
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Genital warts
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Difficulty conceiving
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Number of pregnancies
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Number of live births
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Number of miscarriages
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Number of abortions
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Do you do self breast exams
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Breast lumps
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Breast pain/tenderness
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Nipple discharge
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MALE REPRODUCTIVE
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Are you sexually active?
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Sexual orientation
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Birth control / Type
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Discharge or sores
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Chlamydia
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Gonorrhea
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Genital warts
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Herpes
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Syphilis
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Hernias
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Testicular masses
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Testicular pain
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Prostate disease
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Impotence
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Premature ejaculation
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