ph: 928-649-0269 cornville, az 86325 breakthrough medicine · 2017-11-20 · please list: dosage...
TRANSCRIPT
BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.
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BREAKTHROUGH MEDICINE
SHAIDA SINA, NMD
FEMALE HEALTH HISTORY INTAKE
Last name: First: Middle:
Age: Gender: Marital Status: Date of Birth:
Reason for visit:
Last Medical Visit (date & with whom)
Please Check box if appropriate and note when it was performed.
☐ Thermal or Mammogram: ☐ Colonoscopy or Endoscopy:
☐ Bone Density: ☐ MRI/Cat Scan/Ultrasound/X-ray:
☐ General Blood Work: ☐ Dental Exam:
☐ Hormone Screen: ☐ Eye Exam:
Allergies Reactions (Medicine and Substance):
Please list: Dosage and Frequency of how you are taking Medications and Supplements
Medications (over the counter and prescribed) Supplements (vitamins, amino, herbs….)
Patient Visit Location: Core Chiropractic 2530 W. SR 89A Sedona, AZ 86336
Front Office and Natural Pharmacy: Breakthrough Medicine 10990 Cornville Road, Suite “E”, Cornville, AZ 86325
Phone: 928.649.0269
Fax: 866.644.6363
PRACTICE LOCATION:2530 W. ST. RT. 89A, Suite B1Sedona, AZ 86336
VIRTUAL OFFICE:PO BOX 208Cornville, AZ 86325
Ph: 928-649-0269Fax: 866-644-6363
Email: [email protected]
BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.
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Family History: “F”= Father, “M”=Mother, “S”= Siblings, “GP”= Grandparents, “C”=Children
Allergy: Cholesterol: Brain Issues: Prostate Issues:
Anemia: Digestive Issues: Mental Illness: Thyroid Issues:
Asthma: Diabetes: Heart Attack: Lung Issues:
Blood Pressure: Female Issues: Stroke: Autoimmune:
Cancer: Bone Loss: Eye Issues: Adrenal:
List all Surgeries & Hospitalizations, including date occurred:
Please note “D”= Disease, “I”= Immunized, “N”= Neither (also list most recent booster year)
Small Pox: Rubella: Chicken Pox
Measles: Tetanus: Pertussis (whooping cough):
Mumps: Diphtheria: Haemophilus (HIB):
Hepatitis A: Hepatitis B: Polio:
Pneumococcal: Meningococcal: Influenza:
Rotavirus: RSV: Human Papillomavirus:
Please List All Reactions to Vaccinations:
List “Y”= Yes, “N”= No, “P”= Past regarding use of the following, if “yes”, note amount and how often:
Antacids: Steroids: Antibiotics:
Analgesics: Laxatives: Enema:
Coffee: Alcohol: Soda:
Candy/Cookies: Tobacco: Recreational Drugs:
Present Height: Present Weight: Weight one year ago?
Max. weight? When? Min. weight? When? Ideal Weight:
Do you have good energy throughout the day? Explain:
:
BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.
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Do you experience restful sleep? If you answered “No”, please explain:
List last 10 years of type of work you have done: Are you chemically sensitive to odors? If “Yes”, explain:
What are your hobbies?
Do you use pesticides, herbicides, or other chemicals around your home?
Exercise Routine (type and how often:
Past Medical History: Please Check Box
☐Arthritis ☐Emphysema ☐Cancer ☐Anxiety ☐Structural Injury ☐Kidney Disease
☐Allergies ☐Low Blood Pres. ☐Celiac ☐Depression ☐Hepatitis ☐Gallbladder
Disease
☐Asthma ☐High Blood Pres. ☐Cohn’s Disease ☐Diabetes ☐HIV / AIDS ☐Migraines
☐Alcoholism ☐Diverticulitis ☐GERD (heartburn) ☐Bipolar Disorder ☐Sinusitis ☐Thyroid Issues
☐Alzheimer’s ☐Addiction ☐ Colitis ☐Insomnia ☐Gout ☐Parkinson’s
☐Bronchitis ☐ Schizophrenia ☐Heart Murmur ☐Glaucoma ☐Lupus ☐Osteoporosis
or Osteopenia
☐Chronic Fatigue ☐Eating Disorder ☐Heart Attack ☐Cataract ☐Multiple Sclerosis ☐Pneumonia
☐Cholesterol high ☐Epilepsy/Seizure ☐Angina ☐Concussion ☐Sojourns
Syndrome ☐Tuberculosis
☐Hemorrhoids ☐Varicose Veins ☐Bladder Issues ☐Eczema ☐Psoriasis ☐Acne
Other, not listed:
Female History: Please note: “P” = “Past”, “C” = “Current”, “N” = “Never”
When was you last Female exam?
Period Irregular Endometriosis Ovarian Cyst Uterine Cancer Menopause
Heavy Period Fibrocystic Breast Vaginal Infection Ovarian Cancer Pregnancy #
Fibroids PMS Breast Cancer Abnormal Pap Birth #
)
Are you chemically sensitive to odors? If "YES", explain:
BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.
HEALTH PROFILE
NAME DATE Rate each of the following symptoms upon your typical health profile for:
Point Scale 0 Never or Almost never have the symptom 3 Frequently have it, effect is not severe
1 Occasionally have it, effect is not severe 4 Frequently have it, effect is severe
2 Occasionally have it, effect is severe HEAD HEADACHES DIGESTIVE NAUSEA, VOMITING FAINTNESS TRACT DIARRHEA DIZZINESS CONSTIPATION INSOMNIA BLOATED FEELING TOTAL BELCHING, PASSING GAS
EYES WATERY OR ITCHY EYES HEARTBURN SWOLLEN, REDDENED OR STICKY EYELIDS INTESTINAL / STOMACH PAIN
BAGS OR DARK CIRCLES UNDER EYES TOTAL
BLURRED OR TUNNEL VISION (Does not include near or far-sightedness) JOINTS/ PAIN OR ACHES IN JOINTS
TOTAL MUSCLES ARTHRITIS EARS ITCHY EARS STIFFNESS OR LIMITATION OF MOVEMEMENT
EARACHES, EAR INFECTIONS PAIN OR ACHES IN MUSCLES
DRAINAGE FROM EAR FEELING OF WEAKNESS OR TIREDNESS
RINGING IN EARS, HEARING LOSS TOTAL TOTAL WEIGHT BINGE EATING/DRINKING
NOSE STUFFY NOSE CRAVING CERTAIN FOODS
SINUS PROBLEMS EXCESSIVE WEIGHT HAY FEVER COMPULSIVE EATING SNEEZING ATTACKS WATER RETENTION EXCESSIVE MUCOUS FORMATION UNDERWEIGHT TOTAL TOTAL MOUTH/ CHRONIC COUGHING ENERGY/ FATIGUE, SLUGGISHNESS
THROAT GAGGING, FREQ. NEED TO CLEAR THROAT ACTIVITY APATHY, LETHARGY SORE THROAT, HOARSENESS, LOSS OF VOICE HYPERACTIVITY SWOLLEN OR DISCOLORED TONGUE, GUMS, LIPS RESTLESSNESS CANKER SORES TOTAL TOTAL MIND POOR MEMORY SKIN ACNE CONFUSION, POOR COMPREHENSION
HIVES, RASHES, DRY SKIN POOR CONCENTRATION
HAIR LOSS POOR PHYSICAL COORDINATION
FLUSHING, HOT FLASHES DIFFICULTY IN MAKING DECISIONS
EXCESSIVE SWEATING STUTTERING OR STAMMERING TOTAL SLURRED SPEECH HEART IRREGULAR OR SKIPPED HEART BEAT LEARNING DISABILITIES
RAPID OR POUNDING HEARTBEAT TOTAL
CHEST PAIN EMOTIONS MOOD SWINGS TOTAL ANXIETY, FEAR, NERVOUSNESS
LUNGS CHEST CONGESTION ANGER, IRRITABILITY, AGRESSIVENESS
ASTHMA, BRONCHITIS DEPRESSION SHORTNESS OF BREATH TOTAL
DIFFICULTY BREATHING OTHER FREQUENT ILLNESS TOTAL FREQUENT OR URGENT URINATION
GENITAL ITCH OR DISCHARGE
GRAND TOTAL TOTAL
BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.
FEMALE HORMONE SURVEY
Please score: BLANK= No Symptoms. 1-5 ( 1=Mild 5=Severe )
Hot Flashes
Night Sweats
Irritability
Mood Swings
Weepy
Irregular Periods
Heavy Periods
Bleeding between periods
Low sex drive
Lumpy breasts
Unable to reach orgasm
Painful intercourse
Lack of vaginal lubrication
Breast tenderness
Drooping breasts
Sleep problems
Anxiety or panic attacks
Depression
Loss of motivation
Feeling apathetic
Fatigue
Memory loss
Thinning hair
Dry skin
Cellulite
Decreased muscle strength
Fluid retention
Headache
Joint pain
Muscle pain
Urinary incontinence
Acne
Facial hair growth
Constipation
Food Cravings
Vaginal Discharge
Vaginal Itching
TOTAL
NAME DATE