a aa · 2021. 4. 9. · a mixed food diet (animal and vegetable sources) . o vegetarian a vegan o...
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Medica/ Historya Arthritis
a Allergies/hay fever
a Asthma
a Alcoholism
a Alzheimer's disease
a Autoimmune disease
a Blood pressure problems
a Bronchitis
a Cancer
a Chronic fatigue syndrome
a Carpal tunnel syndrome
a Cholesterol, elevated
a Circulatory problems
a Colitis
a Dental problems
a Depression
a Diabetes
a Diverticular disease
a Drug addiction
a Eating disorder
a Epilepsy
a Emphysemaa Eyes, ears, nose,
throat problems
a Environmental sensitivities
a Fibromyalgiaa Food intolerance
a Gastroesophageal reflux disease
a Genetic disorder
a Glaucoma
a Gout
a Heart disease
a Infection, chronic
a Inflammatory bowel disease
a irritable bowel syndrome
a Kidney or bladder disease
a leaming disabilities
a Liver or gallbladder disease(stones)
a Mental illness
a Mental retardation
a Migraine headaches
a Neurological problems(Parkinson's, paralysis)
a Sinus problems
a Stroke
a Thyroid trouble
a Obesity
a Osteoporosis
a Pneumonia
a Sexually transmitted disease
a Seasonal affective disorder
a Skin problemsa Tuberculosis
a Ulcer
a Urinary tract infection
a Varicose veins
Other _
Medica/ (Men)a Benign prostatic hyperplasia
a Prostate cancer
a Decreased sex drive
a Infertility
a Sexually transmitted disease
Other _
Medica/ (Women)a Menstrual irregularities
a Endometriosis
a Infertility
a Fibrocystic breasts
a Fibroids/ovarian cysts
a Premenstrual syndrome (PMS)
a Breast cancer
a Pelvic inflammatory disease
a Vaginal infections
a Decreased sex drive
a Sexually transmitted disease
Other _
Date of last GYN exam _
Mammogram a + a PAP a + a -Form of birth control _
# of children _
# of pregnancies _
a C-section _
Ageoffi~tperiod _
Date - last menstrual cycle _
length of cycle days
Interval of time between cycles__________ days
Any recent changes in nonmal men·strual flow (e.g., heavier, largeclots, scanty) _
a Surgical menopause
a Menopause
Family Hea/th History
(Parents and Siblings)a Arthritis
a Asthma
a Alcoholism
a Alzheimer's disease
a Cancer
a Depression
a Diabetes
a Drug addiction
a Eating disorder
a Genetic disorder
a Glaucoma
a Heart disease .
o Infertility
a learning disabilities
a Mental illness
a Mental retardation
a Migraine headaches
a Neurological disorders(Parkinson's, paralysis)
a Obesity
a Osteoporosis
a Stroke
a Suicide
Other
Health Habits
a Tobacco:
Cigarettes: #/day _
Ciga~: #/day _a Alcohol:
Wine: #glassesld or wk _
Liquor: #ouncesld or wk _
Beer: #glassesld or wk _a Caffeine:
Coffee: #6 oz cups/d _
Tea: #6 oz cups/d _Soda w/caffeine: #cans/d
Other sources _
a Water: #glassesld _
Exercise
o 5-7 days per week
o 3-4 days per week
o 1-2 days per week
a 45 minutes or more duration perworkout
o 30-45 minutes duration per workout
a less than 30 minutes
a Walk - #days/wk _
a Run, jog, other aerobic - #days/wk
o Weight lift - #days/wk _
a Stretch - #days/wk _
a Other _
Nutrition & Diet
a Mixed food diet (animal andvegetable sources) .
o Vegetarian
a Vegan
o Salt restriction
o Fat restriction
a Starch/carbohydrate restriction
a The Zone Diet
a Total calorie restriction
Specific food restrictions:
a dairy 0 wheat a eggs'
a soy a com a all gluten
Other _
Food Frequency
Number of servings per day:
Fruits (citrus, melons, etc.) _
Dark green or deep yellow/orangevegetables _
Grains (unprocessed) __
Beans, peas, legumes _
Dairy, eggs _
Meat, poultry, fish _
Eating Habits
a Skip meals - which ones _
a One meal/day
a Two meals/day
a Three meals/day
a Graze (small frequent meals)
a Generally eat on the run
a Eat constantly whether hungryor not
Current Supplementsa Multivitamin/mineral
a Vitamin C
a Vitamin E
a EPAlDHA
a Evening Primrose/GLA
a Calcium, source _
a Magnesium
a Zinc
a Minerals, describe _
a Friendly flora (acidophilus)
a Digestive enzymes
a Amino acids
a CoQ10
a Antioxidants (e.g., lutein,resveratrol, etc.)
a Herbs
a Homeopathy
o Protein shakes
o Superfoods (e.g., bee pollen,phytonutrient blends)
a Liquid meals (Ensure)
Others _
I Would LIke To:
ENERGY - VITALITY
a Feel more vital
a Have more energy
a Have more endurance
a Be less tired after lunch
.a Sleep better
a Be free of pain
a Get less colds and flu
a Get rid of allergies
a Not be dependent on over-thecounter medications like aspirin,ibuprofen, anti-histamines, sleeping aids, etc.
a Stop using laxatives and stoolsoftene~
a Improve sex drive
BODY COMPOSITION
a loose weight
a Bum more body fat
a Be stronger
a Have better muscle tone
a Be more flexible
STRESS. MENTAL EMOTIONAL
a learn how to reduce stress
a Think more clearly and be more-focused
a Improve memory
a Be less depressed
a Be less moody
a Be less indecisive
a Feel more motivated
LIFE ENRICHMENT
a Reduce my risk of degenerativedisease
a Slow down accelerated aging
a Maintain a healthier life longer
a Change from a "treating-illness"orientation to creating awellness lifestyle
© 2000 Lyra Heller, Michael Katke. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law.7/00, Rev 1/03, Rev 3/06MET1392
Are you recovering from a cold or flu?
Reason for office visit:
Name _
Occupation
Marital Status: o Single o Partner o Married
Are you pregnant?
_______________ Date
Age Height Sex Number of Children
o Separated 0 Divorced 0 Wldow(er)
Date began:
o acupuncture
o Constipation
o Fecal incontinence
o Urinary incontinence
o Low grade fever
List current health problems for which you are being treated:
What types of therapies have you tried for these problem(s) or to Improve your health over-all:
o diet modification 0 fasting 0 vitamins/minerals 0 herbs 0 homeopathy 0 chiropractic
o other
Do you €xperience any of these general symptoms EVERY DAY?
o Debilitating fatigue 0 Shortness of breath 0 Insomnia
o Depression 0 Panic attacks 0 Nausea
o Disinterest in sex 0 Headaches 0 Vomiting
o Disinterest in eating 0 Dizziness 0 Diarrhea
o conventional drugs
o Chronic pain/inflammation
o Bleeding
o Discharge
Ditching/rash
Current medications (prescription or over-the-counter):
Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis):
Outcome
Major Hospitalizations, Surgeries, Injuries: Please list all procedures, complications (if any) and dates:
Year Surgery, Illness, Injury Outcome
Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 4 5 6 7 8 9 10
Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems):_
Do you consider yourself: 0 underweight 0 overweight 0 just right Your weight today
Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months? _
Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g., fireman, etc.)?
What are your current health goals: