patient intake formdrhabib.ca/wp-content/uploads/2016/03/dr-navaz... ·...

www.drhabib.ca [email protected] 416-523-1766

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

DATE: !! !

Instructions 1. Take your time telling your story. The more

we know, the better we can help. 2. If you are not able to complete the form,

please keep your original appointment. You will have a chance to re-submit after the consultation.

PATIENT INTAKE FORM

PATIENT'INTAKE'FORM''''''''''''1

Name:First Middle Last

Preferred Name

Date of Birth

Age Gender Male Female

Primary AddressNumber, Street Apt#

City Province Postal Code

Genetic Background African European Native AmericanAsian Ashkenazi Middle EasternCaucasian Mediterranean

Highest Education Level High School Undergraduate Post Graduate

Job Title

Nature of Business

Marital Status Single Married Divorced Widowed Common-Law

Home Phone Cell Phone

Work Phone

Email

Emergency ContactName Phone

Primary Care PhysicianName Phone Fax

How did you hear aboutDr. Navaz Habib?

GENERAL INFORMATION


Name Age Gender

Tell me the story about your health:

IN YOUR WORDS


AllergiesMedication / Supplement / Food Reaction

Complaints / Concerns

What do you hope to achieve by working with us?

If you could eliminate three problems permanently, what would they be?

1

2

3

When was the last time you felt well?

Did something trigger a change in health/symptoms?

What makes you feel worse?

What makes you feel better?

MEDICAL QUESTIONNAIRE


ex. Headaches May 2010 1-2x /week Advil Mild Improvement

What diagnosis or explanation(s), if any, have been given to you for these concerns?

What physician or other health care provider have you seen for these conditions? (Include alternative or complimentary practitioners)

How much time have you lost from work or school in the past year due to these conditions?

CURRENT HEALTH STATUS & CONCERNSPlease inform us of current and ongoing problems

Problem Date of Onset Severity / Frequency Treatment Success


Past

Ongo

ing

Past

Ongo

ing

Irritable Bowel Syndrome Lung CancerInflammatory Bowel Disease Breast CancerCrohn's Disease Colon CancerUlcerative Collitis Ovarian CancerGastritis or Peptic Ulcers Prostate CancerGERD (reflux) Skin CancerCeliac Disease OtherGallstonesOther

Past

Ongo

ing

Past

Ongo

ing

Heart Attack Kidney StonesHeart Disease GoutStroke Interstitial CystitisElevated Cholesterol Frequent Urinary Tract InfectionsArrhythmia Frequent Yeast InfectionsHypertension Erectile / Sexual DysfunctionRheumatic Fever OtherMitral Valve ProlapseOther

Past

Ongo

ing

Past

Ongo

ing

Eczema AsthmaPsoriasis Chronic SinusitisAcne BronchitisMelanoma EmphysemaSkin Cancer PneumoniaOther Tuberculosis

Sleep Apnea

MEDICAL HISTORY - DISEASE/DIAGNOSIS/CONDITIONSPlease check appropriate box and provide date of onset (mm/yyyy)

RESPIRATORY DISEASESKIN DISEASE

CARDIOVASCULAR GENITAL AND URINARY SYMPTOMS

CANCERGASTROINTESTINAL


Past

Ongo

ing

Past

Ongo

ing

Chronic Fatigue Syndrome Type 1 DiabetesAutoimmune Disease Type 2 DiabetesRheumatoid Arthritis HypoglycemiaLupus SLE Metabolic SyndromeImmune Deficiency Disease Hypothyroidism (Low Thyroid)Frequent Infections Hyperthyroidism (Overactive Thyroid)Food Allergies Endocrine ProblemsEnvironmental Allergies Polycystic Ovarian SyndromeMultiple Chemical Sensitivities InfertilityLatex Allergy Weight GainHepatitis Weight LossOther Frequent Weight Fluctuations

Bulimia

Anorexia

Binge Eating DisorderOsteoarthritis Night Eating DisorderFibromyalgia Eating Disorder (non-specific)Chronic Pain OtherOther

Past

Ongo

ing

Depression / Anxiety

Bipolar DisorderAnemia SchizophreniaChicken Pox Headaches / MigrainesGerman Measles ADD/ADHDMeasles AutismMononucleosis Parkinson's DiseaseMumps Multiple SclerosisSleep Apnea ALSWhooping Cough Seizures

Alzheimer's Disease

INFLAMMATORY / AUTOIMMUNE METABOLIC / ENDOCRINE

Past

Ongo

ing

MUSCULOSKELETAL / PAIN

NEUROLOGIC / MOOD

Past

Ongo

ing

MISCELLANEOUS



Full Physical Exam AppendectomyBone Density Hysterectomy + / - OvariesColonoscopy Gall BladderCardiac Stress Test HerniaEBT Heart Scan TonsillectomyEKG Dental SurgeryHemoccult Stool Test Joint Replacement (Knee / Hip)MRI Heart Surgery (Bypass)CT Scan Angioplasty or StentUpper Endoscopy PacemakerUpper GI series Other (List Below)UltrasoundMammogramX-RayOther

Back Injury ANeck Injury BHead Injury ABBroken Bones O Rh+Other Unknown

Hospitalizations None

Date Reason

PREVENTIVE TESTS SURGERIES

INJURIES BLOOD TYPE (Please Check One)



Pregnancies Post Partum DepressionCaesarean ToxemiaVaginal Deliveries Gestational DiabetesMiscarriage Baby over 8lbsAbortion Breast FeedingLiving Children for how long?

Age at first period? Mensus Frequency? Length? Pain? Y/NClotting Yes No Has your period ever skipped? Yes No For how longLast Menstrual Period?Use of Hormonal contraception such as? Birth Control Pills Patch Nuva Ring

How Long? Do you use contraception? Yes No Condom IUD Diaphragm

Do you experience breast tenderness, water retention, irritability or PMS symptoms in 2nd half of your cycle?Yes No

Please advise of any other symptoms you feel are significant:Fibrocystic Breasts Endometriosis Fibroids InfertilityPainful Periods Heavy Periods PMS

Breast Biopsy / Date:Normal Abnormal

Results: High Low NormalAre you in Menopause? Yes No Age at Onset?Please Check off if you are experiencing any of the following symptoms:

Hot Flashes Mood Swings Heavy Bleeding Joint PainVaginal Dryness Decreased Libido Loss of bladder control HeadachesWeight Gain Palpitations Concentration / Memory problems

Use of hormone replacement therapy? Yes No How Long?What Type? Estrogen Progesterone Ogen Estrace

Premarin Provera Other:

WOMEN'S DISORDERS / HORMONAL IMBALANCES

Last Mammogram?Last PAP Test?

Last Bone Density?

MENSTRUAL HISTORY (Check box if yes)

OBSTETRIC HISTORY (Check box if yes and provide number of)

GYNECOLOGIC HISTORYFor Women Only


Have you ever had a PSA test done? Yes NoPSA Level: 0-2 2-4 4-10 >10

Prostate Enlargement Prostate InfectionChange in Libido ImpotenceDifficulty Obtaining an Erection Difficulty Maintaining an ErectionNocturia (urination at night) Yes No How many times per night?Urgency/Hesitancy/Change in Urinary System Loss of control of Urine

MEN'S HISTORYFor Men Only


Current MedicationsMedication Dose Frequency Start Date Reason For Use

Previous Medications (Last 10 Years)Medication Dose Frequency Start Date Reason For Use

Nutritional Supplements (Vitamins / Minerals / Herbs / Homeopathy)Supplement & Brand Dose Frequency Start Date Reason For Use

Do your medications / supplements ever cause you unusual side effects / problems? Yes NoDescribe:

Have you had prolonged or regular use of NSAIDs (Advil, Aleve, etc), Motrin, Aspirin? Yes NoHave you had prolonged or regular use of Tylenol? Yes NoHave you had prolonged or regular use of Acid Blocking Drugs (Zantac, Prilosec etc.)? Yes NoFrequent Antibiotics (>3 times /year)? Yes NoLong term antibiotics? Yes NoUse of steroids (prednisone, nasal allergy inhalers) in the past? Yes NoUse of oral contraceptives? Yes No

MEDICATIONS


Were you a full term baby?A premature birth?Vaginal Delivery?C-SectionBreast fed?Bottle fed?

Smoke Tobacco?Use Recreational Drugs?Drink Alcohol?Use Estrogen?

SmallpoxTetanusDiphtheriaPertussesPolio (Oral)Polio (Injection)MumpsMeaslesRubella (German Measles)TyphoidCholera

WHEN PREGNANT WITH YOU, DID YOUR MOTHER:

Other prescription or non-prescription medications?

Yes No Don't Know Comment

CHILDHOOD HISTORYPlease answer to the best of your knowledge

IMMUNIZATION HISTORYPlease indicate if you have been vaccinated against the following infectious diseases?



Was your childhood diet high in:Sugar? (Swetts, Candy, Cookies etc.)Soda?

Milk, Cheeses or other Dairy products?Meat, Vegetables and Potato Diet?Vegetarian Diet?Diet high in wheat (bread, cereal, pasta)?As a child, were there food that you had to avoid because they gave you symptoms? Yes No

If yes, please expain (Ex. Milk cause Diarrhea)

Yes Age Yes AgeAttention Deficit Disorder (ADD) MumpsAsthma PneumoniaBronchitis Seasonal AllergiesChicken Pox Skin DisordersColic Strep InfectionsCongenital Problems TonsillitisEar Infections Upset Stomach, Digestive ProblemsFever Blisters Whooping CoughFrequent colds or flu MeaslesFrequent Headaches Other (describe)Hyperactivity Other (describe)Jaundice Other (describe)As a child did you have a high absence from school Yes No

If yes, why?Experience chronic exposure to second hand smoke in your home? Yes NoExperience abuse? Yes NoHave alcoholic parents? Yes No

CHILDHOOD DIET

CHILDHOOD ILLNESSES

Fast food, prepackaged foods, artificial sweeteners?


Please indicate which of the following problems/conditions you experienced as a child (age birth to 12 years) and the approximate age of onset.


Please check all family members that apply

Fath

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Age (if still living)Heart AttackAge at death (if deceased)Uterine CancerColon CancerBreast CancerOvarian CancerProstate CancerSkin CancerADD/ADHDALS or other Motor Neuron DiseasesAlzheimer’sAnemiaAnxietyArthritisAsthmaAutismAutoimmune Diseases (such as Lupus)Bipolar DiseaseBladder diseaseBlood clotting problemsCeliac diseaseDementiaDepressionDiabetesEczemaEmphysemaEnvironmental Sensitivities

FAMILY HEALTH HISTORYPlease indicate current and past history to the best of your knowledge.


Please check all family members that apply

Fath

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dmot

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EpilepsyFluGenetic DisordersGlaucomaHeadacheHeart DiseaseHigh Blood PressureHigh CholesterolInflammatory Arthritis (Rheumatoid,Psoriatic, Ankylosing spondylitis)Inflammatory Bowel DiseaseInsomniaIrritable Bowel SyndromeKidney diseaseMultiple SclerosisNervous breakdownObesityOsteoporosisOtherParkinson’sPneumonia/BronchitisPsoriasisPsychiatric disordersSchizophreniaSleep ApneaSmoking addictionStrokeSubstance abuse (such as alcoholism)Ulcers

FAMILY HEALTH HISTORYPlease indicate current and past history to the best of your knowledge.


Fever Poor Concentration Cuts heal slowlyChills/Cold all over Confusion Bruise easilyAches/Pains Headaches: RashesGeneral Weakness After Meals PigmentationDifficulty sweating If meals skipped? Changing MolesExcessive Sweating Severe CallusesSwollen Glands Migraine EczemaCold hands & Feet Frontal PsoriasisFatigue Occipital Dryness/cracking skinDifficulty falling asleep Afternoon OilinessSleepwalker Daytime ItchingNightmares Relieved by: AcneNo dream recall Eating Sweets BoilsEarly waking Concussion/Whiplash HivesDaytime sleepiness Mental sluggishness Fungus on NailsDistorted vision Forgetfulness Peeling Skin

Indecisive ShinglesFace twitch Nails SplitPoor Memory White Spots/Lines on Nails

Aches Hair Loss Crawling SensationDischarge Burning on Bottom of FeetPains Athletes FootRinging CelluliteDeafness/Hearing loss Feeling of sand in eyes Bugs love to bite youItching Double/blurred vision Is your skin sensitive to?:Pressure Conjunctivitis SunHearing Aid Poor night vision FabricsFrequent Infections See bright flashes DetergentsTubes in Ears Halo around lights Lotions/CreamsSensitive to loud noises Eye painsHearing Hallucinations Dark circles under eyes

Strong light irritatesCataractsVisual hallucinations

Past

HEAD Past

Ongo

ing

SKINOngo

ing

GENERALPast

Ongo

ing

EARS

EYES

REVIEW OF SYMPTOMS - PART 1


Stuffy Swollen Ankles StiffnessBleeding Sensitive to hot SwellingRunning/Discharge Sensitive to cold LumpsWatery nose Extremities cold or clammy Neck glands swellCongested Hands/Feet NumbnessInfection High Blood PressurePolyps Chest PainAcute smell Pain between shoulders Coated tongueDrainage Dizziness upon standing Sore tongueSneezing spells Fainting Spells Dental problemsPost nasal drip High cholesterol Bleeding gumsNo sense of smell High triglycerides Canker soresDo changing seasons Wheezing TMJmake symptoms worse? Irregular heartbeat Cracked lips/ corners

Yes No Palpitations Chapped lipsIf yes, is it worse in the: Low exercise tolerance Fever blisters

Spring Frequent coughs Wear denturesSummer Breathing heavily Grind teeth when sleepingFall Frequently sighing Bad breathWinter Shortness of breath Dry mouth

Night sweatsVaricose veins/spider veinsMitral valve prolapseMurmurs MucusSkipped heartbeat Difficulty swallowingHeart enlargement Frequent hoarsenessAngina pain Enlarged glandsBronchitis/Pneumonia Constant clearing of throatEmphysema Throat closes upFrequent colds TonsillitisHeavy/tight chestPrior heart attack ?When ____/_____/_____Phlebitis

Past

Ongo

ing

Past

NOSE / SINUSES Ongo

ing

CIRCULATION / RESPIRATION Past

Ongo

ing

NECK

MOUTH

THROAT



Peptic/Duodenal Ulcer Prostate enlargement Fibrocystic breastsPoor appetite Prostate infection Lumps in breastExcessive appetite Poor/Change in libido Fibroid Tumors/BreastGallstones Impotence SpottingGallbladder pain Infertility Heavy periodsNervous stomach Lumps in testicles Fibroid Tumors/UterusFeel full after small meal Sore on penis Painful periodsIndigestion Genital pain Change in periodHeartburn Hernia Breast soreness pre periodAcid Reflux Prostate cancer EndometriosisHiatal Hernia Low sperm count Non-period bleedingNausea Difficulty obtaining erection Breast soreness post periodVomiting Vaginal drynessVomiting blood Vaginal dischargeAbdominal Pain/Cramp Nocturia (urination at night) Partial/total hysterectomyGas How many times at night? Hot flashesDiarrhea Mood swingsConstipation Concentration ProblemsChanges in bowels Loss of bladder control Memory ProblemsRectal bleeding Breast cancerTarry stools Ovarian cystsRectal itching PregnantUse laxatives Burning InfertilityBloating Frequent urination Decreased libidoBelch frequently Blood in urine Heavy bleedingAnal itching Night time urination Joint painsAnal fissures Problem passing urine HeadachesBloody stools Kidney pain Weight gainUndigested food in stool Kidney stones Loss of bladder control

Painful urination PalpitationsBladder infectionsKidney infectionsSyphilisBedwettingTrichomonas

Past

Ongo

ing

GASTROINTESTINAL Past

Ongo

ing

MEN'S HISTORY For Men Only Pa

st

Ongo

ing

WOMEN'S HISTORY For Women Only

Difficulty maintaining an erection

Urgent/Hesitant/change in urinary stream


KIDNEY / URINARY TRACT


Convulsions IrritableDizziness Feeling of hostility/volatile orFainting Spells aggressiveBlackouts/Amnesia FatigueHad prior shock therapy HyperactiveFrequently keyed up and jittery Restless leg syndromeStartled by sudden noises Considered clumsyAnxiety/Feeling of panic Vision changesGo to pieces easily Unable to coordinate muscleForgetful Have difficulty falling asleepListless/groggy Have difficulty staying asleepWithdrawn feeling/Feeling 'lost' Daytime sleepinessHad nervous breakdown WorkaholicUnable to concentrate/short Have had hallucinationsattention spanUnable to reasonTends to worry needlesslyConsidered a nervous person Pain wakes youby others Weakness in legs and armsUnusual tension Balance problemsFrustration Muscle crampingEmotional numbness Head injuryOften break out in cold sweats Muscle stiffness in morningProfuse sweating Damp weather bothers youDepressedOften awakened byfrightening dreamsPreviously admitted forpsychiatric careFamily member had nervousbreakdownUse tranquilizersMisunderstood by others

EMOTIONAL (Continued)Past

Ongo

ing

EMOTIONAL Past

Ongo

ing

REVIEW OF SYMPTOMS PART 4

JOINTS / MUSCLES / TENDONS


Are you currently in pain? Yes NoIs the source of your pain due to an injury? Yes No

If yes, please describe your injufy and the date on which it occurred:

If no, please describe how long you have experienced this pain and what you believe it is attributed to:

Please use the area(s) and illustrations below to describe the severity of your pain (0=no pain, 10=worst possible)Example: Neck 5

Area 1. Area 3.

Area 2. Area 4.

Use the letters provided to mark your areas of pain on the illustration:A = aching B = burning N = numbness S = stiffness T = tingling Z = sharp/shooting

PAIN ASSESSMENT


Do you have amalgam dental fillings? How many?Did you receive these fillings as a child?Do you have Gold Fillings?Do you have Root Canals?Implants?Tooth Pain?Bleeding Gums?Gingivitis?

List your approximate age and the type of dental work done from childhood until present:

Age Type of Dental Work Health Problems following dental work? (describe)

Have TMJ (temporal mandibular joint) problems?Metallic taste in mouth?Problems with bad breath (halitosis) or white tongue (thrush)?Previously or currently wear braces?Problems chewing?

NoYesProblem with sore gums (gingivitis)?Ringing in the ears (tinnitus)?

DENTAL HISTORY

Floss regularly?


Height (feet / inches) Current Weight:Usual Weight +/- 5lbs Desired weight (+/- 5lbs)Highest Adult Weight Lowest Adult WeightWeight Fluctuations (>10lbs) Body Fat %How often do you weigh yourself? Daily Weekly Monthly Rarely Never

Do you grocery shop? Yes NoIf no, who does the shopping?

Do you avoid any particular foods Yes NoIf yes, types and reason:

If you could only eat a few foods each week, what would they be?

Do you cook? Yes NoIf no, who does the cooking?Do you read food labels? Yes NoHow many meals do you eat out per week? 0-1 1-3 3-5 >5 per week

Please check off all factors that apply to your current lifestyle and eating habitsErratic eating pattern Love to eatFast Eater Eat because I have toLate night eating Have a negative relationship with foodDislike healthy food Struggle with eating issuesFamily members don't like healthy food Emotional eater (eat when sad, bored, depressed)Eat more than 50% meals away from home Eat too much under stressTravel frequently Eat too little under stressNon-availability of healthy foods Don’t care to cookDo not plan meals or menus Eating in the middle of the nightReliance on convenience Confused about nutrition advicePoor snack choices Family members have special dietary needsTime constraints Eat too much

The most important thing that I should change about my diet to improve my health is:

SOCIAL HISTORY


Have you made any changes in your eating habits because of your health? Yes No

Food Diary - Place a check mark next to the food/drink that applies to your current diet

None None NoneBacon/Sausage Butter Beans (legumes)Bagel Coffee Brown riceButter Eat in a cafeteria ButterCereal Eat in restaurant CarrotsCoffee Fish sandwich CoffeeDonut Fried foods FishEggs Hamburger Green vegetablesFruit Hot dogs JuiceJuice Juice MargarineMargarine Leftovers MilkMilk Lettuce PastaOat bran Margarine PotatoSugar Mayo PoultrySweet roll Meat sandwich Red meatSweetener Milk RiceTea Pizza SaladToast Potato chips Salad dressingWater Salad SodaWheat bran Salad dressing SugarYogurt Soda SweetenerOatmeal Soup TeaMilk protein shake Sugar VinegarSlim fast Sweetener WaterCarnation shake Tea White riceSoy protein Tomato Yellow vegetablesWhey protein Vegetables Other: (List below)Rice protein WaterOther: (List below) Yogurt

Protein ShakeOther:

USUAL DINNERUSUAL BREAKFAST USUAL LUNCH

NUTRITIONAL HISTORY - PART 1


How much of the following do you consume each week?

CandyCheeseChocolateCups of coffee containing caffeineCups of decaffeinated coffee or teaCups of Hot chocolateDiet SodaIce CreamSalty foodsSlices of white bread (rolls,bagels,etc)Soda with caffeineSoda without caffeineCups of tea containing caffeine

Do you currently follow a special diet or nutritional program? Yes NoGluten-Free Diabetic Dairy Restricted Vegan Vegetarian Blood Type

Other:Is there anything special about your diet that I should know:

Do you have symptoms immediately after eating (belching, bloating, sneezing, hives, etc.) Yes NoIf yes, are these symptoms associated with any particular food or supplement? Yes NoIf yes, please name the food or supplement, and symptom(s):

Do you feel that you have delayed symptoms after eating certain foods, such as fatigue, muscle aches, sinuscongestion, etc? (symptoms may not be evident for 24 hours or more) Yes No

Do you feel WORSE when you eat a lot of: Do you feel BETTER when you eat a lot of:High Fat Foods High Fat FoodsHigh Protein Foods High Protein FoodsHigh Carbohydrate Foods High Carbohydrate Foods (breads, pasta, potatoes) (breads, pasta, potatoes)Refined sugar ( junk food) Refined sugar ( junk food)Fried foods Fried foods1-2 alcoholic drinks 1-2 alcoholic drinksOther: Other:



Does skipping meals greatly affect your symptoms? Yes NoHas there ever been a food that you have craved or ‘binged’ on over a period of time? Yes No

If yes, what food(s)

How many times do you chew your food?How much fluid to you drink with your meals?How many servings of fruits & vegetables do you eat per week?What foods do you dislike?What foods do you not tolerate well or do you react to?What type of cuisine do you like?What is your typical breakfast?How much time do you have in the morning to prepare breakfast?What is your typical lunch?What is your typical dinner?What meats do you eat?Do you eat eggs?Do you ever do vegetarian? If so how often?What foods do you crave?Do you have snacks during the day? If so what do you snack on?Do you eat fish or other seafood? If so what types?Do you eat dessert? If so what do you eat?Do you skip any meals?What time do you eat your breakfast, lunch, dinner?What time do you usually eat snacks?What types of beverages do you consume?How many ounces/mls of water do you consume daily?What oils do you cook with?Caffeine Intake: Yes No

Coffee Cups/day: 1 2-4 >4 per dayTea Cups/day: 1 2-4 >4 per day

Caffeinated Sodas or Diet Sodas Intake: Yes No12-ounce can/bottle: 1 2-4 >4 per day

List favorite type (Ex. Diet Coke, Pepsi, etc.):



Foreign Travel? Yes No Where?Wilderness Camping? Yes No Where?Have you ever had severe? Gastroenteritis DiarrheaDo you feel like you diegest your food well?Do you feel bloated after meals?

Please complete the following chart as it relates to your bowel movements:

FREQUENCY CONSISTENCYMore than 3x a day Soft and well formed1-3x a day Often floats4-6x a week Difficult to pass2-3x a week Diarrhea1 or fewer x a week Thin, long or narrow

Small and hardLoose but not wateryAlternating between hard and loose / watery

COLOR INTESTINAL GASMedium brown consistently DailyVery dark or black OccasionallyGreenish color ExcessiveBlood is visible Present with PainVaries a lot Foul SmellingDark brown consistently Little OdorYellow, light brownGreasy, shiny appearance

DIGESTIVE HISTORY


SmokingCurrently Smoking? Yes No How many years? Packs per day?Attempts to quit:Previous Smoking: How many years? Packs per day?Second Hand Smoke?

Alcohol IntakeHow many drinks currently per week? 1 drink = 5oz wine, 12oz beer, 1.5oz spirits

None 1-3 4-6 7-10 >10 If None, skip to Other SubstancesPrevious Alcohol intake? Yes ( Mild Moderate High) None

Have you been told you should cut down your alcohol intake? Yes NoDo you get annoyed when people ask you about your drinking? Yes NoDo you feel guilty about your alcohol consumption? Yes NoDo you ever take an eye opener? Yes NoDo you notice a tolerance to alcohol (can you hold more than others)? Yes NoHave you ever been unable to remember what you did during a drinking episode? Yes NoDo you get into arguments or physical fights when you have been drinking alcohol? Yes NoHave you ever been hospitalized because of drinking? Yes NoHave you ever thought about getting help to control or stop your drinking? Yes No

Other SubstancesAre you currently using any recreational drugs? Yes No Type:Have you ever used IV or inhaled recreational drugs? Yes No Type:

LIFESTYLE HISTORY


Do you exercise regularly? Yes No

Current exercise program (List type of activity, number of sessions/week and duration)

Activity Type Frequency/week Duration (mins)Stretching/Jogging/WalkingCardio/AerobicsStrength TrainingYoga/Pilates/Gyrotnics etc.Sports/Leisure Activities(golf, tennis, rollerblading etc.)Other

Rate your level of motivation for including exercise in your life Low Medium HighList problems that limit activity:

Do you feel unusually fatigued after exercise? Yes NoIf yes, please describe:

Do you usually sweat when exercising? Yes No

Do you feel significantly less vital than you did a year ago? Yes NoAre you happy? Yes NoDo you feel your life has meaning and purpose? Yes NoDo you still believe stress is presently reducing the quality of your life? Yes NoDo you like the work you do? Yes NoHave you ever experienced major losses in your life? Yes NoDo you spend the majority of your time and money to fulfill responsibilities and obligations? Yes NoWould you describe your experience as a child in your family as happy and secure? Yes No

EXERCISE

PSYCHOSOCIAL


Have you ever sought counselling? Yes NoAre you currently in therapy? Yes NoDo you feel you have an excessive amount of stress in your life? Yes NoDo you feel that you can easily handle the stress in your life? Yes NoDaily Stressors - Rate on a scale of 1 to 10 (1 = minimal stress, 10 = very high stress):

Work Family Social Finances Health Other

Do you practice meditation or relaxation techniques? Yes No

Check all that apply:Yoga Meditation Imagery Breathing Tai Chi Prayer

Have you ever been abused, a victim of crime, or experienced significant trauma? Yes NoHobbies and Leisure Activities:

Average number of hours you sleep per night >10 8-10 6-8 <6Do you have trouble falling asleep? Yes NoDo you feel rested upon awakening? Yes NoDo you have problems with insomnia? Yes NoDo you snore? Yes NoDo you use sleep aids? Yes NoWhat time do you go to bed?What time do you wake up?

STRESS/COPING

SLEEP AND REST


List Children

CHILD'S NAME AGE GENDER

Who is living in your household? Number: Names:Their Employment/Occupations:Resources for emotional support?

Spouse Family Friends Religious/Spiritual Pets OtherAre you satisfied with the quality of your sexual life? Yes No

OverallAt schoolIn your jobIn your social lifeWith close friendsWith sexual lifeWith your attitudeWith your boyfriend/girlfriendWith your childrenWith your parentsWith your spouse

Very Well Not ApplicableFine Poorly

ROLES/RELATIONSHIPS

HOW WELL HAVE THINGS BEEN GOING FOR YOU?


Do you have known adverse food reactions or sensitivities? Yes NoIf yes, describe symptoms:

Do you have any food allergies or sensitivities? Yes NoList all:

Do you have an adverse reaction to caffeine? Yes NoWhen you drink caffeine, do you feel?

Do you adversely react to (Check all that apply):Monosodium Glutamate (MSG) Aspartame Caffeine BananasGarlic Onion Chese Citrus FoodsChocolate Alcohol Red Wine Sulfite containing foodsPreservatives (Sodium Benzoate) Other: (wine, dried fruit etc.)

Which of these signficantly affect you? (Check all that apply)Cigarette Smoke Perfumes/colognes Auto exhaust fumes Other:

In your work or home environment, are you exposed to:Chemicals Electromagnetic Radiation Mold

Have you ever turned yellow ( jaundiced)? Yes No

Have you ever been told you have Gilbert's syndrome or a Liver disorder? Yes NoExplain:

Do you have a known history of significant exposure to any harmful chemicals such as:Herbicides Insecticides Pesticides Organic SolventsLead Arsenic Aluminum CadmiumMercury Other:

Chemical Name, Date, Length of Exposure:Do you dry clean your clothes frequently? Yes NoHave you ever lived or worked in a damp or moldy environment? Yes NoDo you have any pets or animals? Yes NoWhat type/brands of personal care products do you use (deodorant, lotion, soaps)?

ENVIRONMENTAL & DETOXIFICATION ASSESSMENT


Life EventDeath of Spouse 100Divorce 73Marital Separation 65Detention in Jail or other Institution 63Death of a close family member 63Major personal injury or illness 53Marriage 50Being tired from work 47Marital reconciliation 45Retirement from work 45Major change in health or behavior of a family member 44Pregnancy 40Sexual Difficulties 39Gaining a new family member (birth, adoption, older adult moving in, etc.) 39Major Business readjustment 39Major change in financial state (a lot worse or better off than usual) 38Death of a close friend 37Changing to a different line of work 36Major change in number of arguments with spouse on core issues 35Taking on a mortgage (for home, business, etc.) 31Foreclosure on a mortgage or loan 30Major change in responsibilities at work (promotion,demotion, etc.) 29Son or daughter leaving home (marriage, college, etc.) 29Conflict or tension with parents/in laws 29Outstanding personal achievement 28Spouse beginning or ceasing work outside the home 26Beginning or completing formal schooling 26Major change in living condition (new home, remodeling, deterioration of home) 25Change of personal habits (dress, manners, association, quitting, smoking) 24Conflict at work with employer or manager 23Major changes in working hours or conditions 20Changes in residence 20Changing to a new school 20Major change in usual type/ or amount of recreation 19Major change in church activity (a lot more or less than usual) 19Major change in social activities (clubs, movies, visiting, etc) 18Taking on a loan (car, TV, appliances, etc..) 17Major change in sleeping habits (a lot more or less than usual) 16Major change in number of family get-togethers 15Major change in eating habits (food amount, meal hours or surrounding) 15Vacation 13Major holidays 12Minor violations of the law (traffic tickets, etc.) 11

Your Total

YesPoints

PERSONAL STRESS INVENTORY


For each of the 10 word groups below, select the word that is MOST like you, LEAST like you and IN BETWEEN.Please assign the following on each line: 4 points to the word that is MOST LIKE YOU

3 points to the word that is LIKE YOU2 points to the word that is SOMEWHAT LIKE YOU1 point to the word that is LEAST LIKE YOU

There should be a 4, 3, 2 and a 1 on each line. See the example below.Example

1. Determined Convincing Predictable Cautious

1. Determined Convincing Predictable Cautious2. Strong Willed Persuasive Easy-going Orderly3. Direct Expressive Kind Analytical4. Bold Sociable Cooperative Precise5. Outspoken Animated Patient Logical6. Decisive Talkative Loyal Controlled7. Daring Outgoing Agreeable Careful8. Restless Enthusiastic Considerate Thorough9. Competitive Inspiring Consistent Detailed

10. Aggressive Playful Satisfied AccurateOnce you have assigned numbers to all 10 word groups, total the points for each columnand write the total in the spaces provided below.

TotalsStyles D I S C

3 4 1 2

DISC SCORING SHEETIn order to determine your Communication Style, please complete the following:


Rate on a scale of: 5 (very willing) to 1 (not willing)

In order to improve your health, how willing are you to: 5 4 3 2 1Significantly modify your dietTake nutritional supplements each dayKeep a good record of everything you eat each dayModify your lifestyle (eg. Work demands, sleep habits)Practice relaxation techniquesEngage in regular exerciseHave periodic lab tests to assess progress

Comments:

Thank you for taking the time to complete this health history questionnaire. The information derived from all of these formswill provide invaluable data in identifying the underlying problems of your health concerns rather than simply treatingthe symptoms alone.

We look forward to helping you achieve lifelong health and well being!

READINESS ASSESSMENT

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