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Natural Integrative Healthcare | Patricia L. Diefenbach, ND, MS, CNC, CNS® | Naturopathic Physician [email protected] | Phone: (703) 609-‐8717
ADULT HEALTH HISTORY FORM
Patient Name: ____________________________________ Date: __________
DOB: _______/_______/________ Age: _______
Address: _____________________________________________________________________________
City, State, Zipcode: ___________________________________________________________________
Telephone (home):________________________ Email:_______________________________________
Status: Married Separated Divorced Widowed Single Partnership
Work Address: ________________________________________________________________________
Job Status: Full-time Part-time Retired Student Other: _______________
Occupation: ____________________________________ Hours/week:____________________________
Employer: _____________________________________________________________________________
Emergency Contact: ______________________ Relationship to Patient:__________________________
Emergency Contact Phone: ___________________________
Emergency Contact Address: _____________________________________________________________
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CONTEXT OF CARE REVIEW
Successful health care and preventive medicine are only possible when the provider has a complete understanding of the physical, mental and emotional aspects. The nature of your responses to the following questions will greatly assist my understanding of your innermost goals. Your time, thoughtfulness and honesty in completing this overview will greatly aid me with your health needs.
What do you know about a naturopathic approach?
What three expectations do you have from this visit?
1. __________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________
What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Please check your selection below)
___0 ___1 ___2 ___3 ___4 ___5 ___6 ___7 ___8 ___9 ___10 (0 = not committed and 10 = completely committed)
What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? (Please list)
What behaviors or lifestyle habits do you currently engage in regularly that you believe are self-destructive lifestyle habits? (Please list)
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What potential obstacles do you foresee in addressing the lifestyle factors, which are undermining your health and in adhering to the therapeutic protocols, which we will be sharing with you?
Who do you know, who will sincerely support you consistently with the beneficial lifestyle changes you will be making? _______________________________________________________________________________________
WHEEL OF BALANCE
Wellness is a balance of many factors. Using the circle, shade your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, shade the entire pie shape for career. Do the same for each area, starting from the center point radiating outwards. (Print and shade using a pen/pencil orfill in the section below with your numerical responses)
Physical Environment _____% Career _____% Money _____% Health _____% Significant Other/Romance _____% Fun & Recreation _____% Personal Growth _____% Family & Friends _____%
Physical Environment
Money
Health
Family & Friends
Personal Growth
Fun & Recreation
Significant Other/Romance
Career
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Are you currently receiving health care?
___ Yes If yes, where and from whom? ____________________________________________ ___ No If no, when and where did you last receive medical or health care and what was the reason?___________________________________________________________________
What are your most important health problems? List as many as you can in order of importance:
1. __________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________
4. __________________________________________________________________________
5. __________________________________________________________________________
6. __________________________________________________________________________
Do you have any, known contagious diseases at this time? ___ Yes ___ No (If yes, please list below)
____________________________________________________________________________
CHILDHOOD ILLNESSES
Scarlet Fever ___Y ___ N Mumps ___Y ___ N
Diphtheria ___Y ___ N Measles ___Y ___ N
Rheumatic fever ___Y ___ N German Measles ___Y ___ N
HOSPITALIZATIONS AND SURGERY
What hospitalizations or surgeries have you had?
Procedure/Year: ______________________________________________________________________
Procedure/Year: ______________________________________________________________________
Procedure/Year: ______________________________________________________________________
Procedure/Year: ______________________________________________________________________
Procedure/Year: ______________________________________________________________________
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X-RAYS AND SPECIAL STUDIES
X-rays, CAT scans, or other studies you have had:
Procedure/Year: ______________________________________________________________________
Procedure/Year: ______________________________________________________________________
Procedure/Year: ______________________________________________________________________
Has your ever had an electrocardiogram? ___ Yes ___ No IMMUNIZATIONS (Please indicate any adverse reactions)
___ Pertussis ___ Polio ___ Measles/Mumps/Rubella ___ Tetanus shot
___ Diptheria ___ Chickenpox ___ Hepatitis ___ Other: _______________ ALLERGIES
Are you hypersensitive or allergic to any drugs? ___ Yes ___ No (If yes, please list below)
_____________________________________________________________________________________
Are you hypersensitive or allergic to any foods? ___ Yes ___ No (If yes, please list below)
_____________________________________________________________________________________
Are you hypersensitive or allergic to any environmental or chemical sensitivities? ___ Yes ___ No (If yes, please list below)
_____________________________________________________________________________________
CURRENT MEDICATIONS
Do you take or use?
Laxatives ___Y ___ N Pain relievers ___Y ___ N
Cortisone ___Y ___ N Appetite suppressants ___Y ___ N
Tranquilizers ___Y ___ N Thyroid medications ___Y ___ N
Antacids ___Y ___ N Antibiotics ___Y ___ N
Sleeping Pills ___Y ___ N
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Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking.
1. _________________________________ 4. _________________________________
2. _________________________________ 5. _________________________________
3. _________________________________ 6. _________________________________
GENERAL
Height: ____________ Weight: ____________ lbs. Weight 1 year ago: ____________ lbs.
Maximum Weight: ____________ When: ____________
At what part of the day is your energy level the best? _____________________________
At what part of the day is your energy level the worst? _____________________________
TYPICAL FOOD INTAKE
Breakfast ____________________________________________________________________________
Lunch ____________________________________________________________________________
Dinner ____________________________________________________________________________
Snacks ____________________________________________________________________________
Beverages (include water) ______________________________________________________________
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FAMILY HISTORY
Do you have a family history of any of the following? (Please select and indicate relation)
Cancer ___Y ___ N (Relationship: _____________________)
Anemia ___Y ___ N (Relationship: _____________________)
High blood pressure ___Y ___ N (Relationship: _____________________)
Diabetes ___Y ___ N (Relationship: _____________________)
Mental Illness ___Y ___ N (Relationship: _____________________)
Tuberculosis ___Y ___ N (Relationship: _____________________)
Epilepsy ___Y ___ N (Relationship: _____________________)
Heart disease ___Y ___ N (Relationship: _____________________)
Hayfever ___Y ___ N (Relationship: _____________________)
Arthritis ___Y ___ N (Relationship: _____________________)
Glaucoma ___Y ___ N (Relationship: _____________________)
Kidney disease ___Y ___ N (Relationship: _____________________)
Hives ___Y ___ N (Relationship: _____________________)
Asthma ___Y ___ N (Relationship: _____________________)
Stroke ___Y ___ N (Relationship: _____________________)
What is your heritage?
___ African ___ Asian ___ Celtic ___ Nordic ___ Other: _____________________
Any other relevant family history?
____________________________________________________________________________
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HABITS
What are your main interests and hobbies?
Do you exercise? ___ Yes ___ No (If yes, please list what kind below)
_______________________________________________________________________________________
CONDITIONS (Please make your selection from the following)
Y = a condition you have now N = a condition you never had P = a condition you have had in the past Average 6-8 hrs. sleep Enjoy your work
Awaken rested Take vacations
Have a supportive relationship Watch television Hours: _____
Have a history of abuse Read Hours: _____
Any major traumas Do you eat 3 meals a day?
Use recreation drugs Do you go on diets often?
Been treated for drug dependence Do you eat out often?
Treated for alcoholism Do you drink coffee?
Use alcoholic beverages Drink black/green tea?
Do you use tobacco Drink cola/soda?
Smoked previously? Do you eat refined salt?
How many years? Do you add salt?
How many packs per day?
Do you have a religious or spiritual practice?
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REVIEW OF SYSTEMS
Mental/Emotional Y = a condition you have now N = a condition you never had P = a condition you have had in the past Treated for emotional problems Depression
Mood Swings Anxiety or nervousness
Considered/Attempted suicide Tension
Poor concentration Memory Problems
Immune Y = a condition you have now N = a condition you never had P = a condition you have had in the past Reactions to immunizations Reactions to vaccinations Chronic Fatigue Syndrome Chronic/Recurring infections Chronically swollen glands Slow wound healing
Endocrine Y = a condition you have now N = a condition you never had P = a condition you have had in the past Hypothyroid Heat or cold intolerance
Hypoglycemia Numbness or tingling
Excessive thirst Easily stressed
Fatigue Loss of balance
Neurologic Y = a condition you have now N = a condition you never had P = a condition you have had in the past Seizures Paralysis Muscle weakness Numbness or tingling Loss of memory Easily stressed Vertigo or dizziness Loss of balance
Skin Y = a condition you have now N = a condition you never had P = a condition you have had in the past Rashes Eczema, Hives
Acnes, Boils Itching
Color Change Perpetual hair loss
Lumps Night Sweats
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Head Y = a condition you have now N = a condition you never had P = a condition you have had in the past Headaches Head Injury Migraines Jaw/TMJ Problems
Ears Y = a condition you have now N = a condition you never had P = a condition you have had in the past Impaired hearing Ringing Earaches Dizziness
Nose and Sinuses Y = a condition you have now N = a condition you never had P = a condition you have had in the past Frequent colds Nose Bleeds Stuffiness Hayfever Sinus problems Loss of smell
Mount and Throat Y = a condition you have now N = a condition you never had P = a condition you have had in the past Frequent sore throat Copious saliva Teeth grinding Sore tongue/lips Gum problems Hoarseness Dental cavities Jaw clicks
Neck Y = a condition you have now N = a condition you never had P = a condition you have had in the past Lumps Swollen glands Goiter Pain or stiffness
Respiratory Y = a condition you have now N = a condition you never had P = a condition you have had in the past Cough Wheezing Spitting up blood Bronchitis Asthma Pleurisy Pneumonia Difficulty breathing Emphysema Shortness of breath Tuberculosis Shortness of breath at night Sputum Shortness of breath lying down
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Cardiovascular Y = a condition you have now N = a condition you never had P = a condition you have had in the past Heart disease Angina High/Low blood pressure Murmurs Blood clots Fainting Phlebitis Palpitations/Fluttering Rheumatic Fever Chest Pain Swelling in ankles
Gastrointestinal Y = a condition you have now N = a condition you never had P = a condition you have had in the past Trouble swallowing Heartburn Change in thirst Abdominal pain or cramps Change in appetite Belching or passing gas Nausea/vomiting Constipation Ulcer Diarrhea Jaundice (Yellow Skin) Bowel movements How often: __ Gall Bladder disease Is there any change? Liver disease Black stools Hemorrhoids Blood in stool
Urinary Y = a condition you have now N = a condition you never had P = a condition you have had in the past Pain on urination Increased frequency Frequency at night Inability to hold urine Frequent infections Kidney stones
Musculoskeletal Y = a condition you have now N = a condition you never had P = a condition you have had in the past Joint pain or stiffness Arthritis Broken bones Weakness Muscle spasm or cramps Sciatica
Blood/Peripheral Vascular Y = a condition you have now N = a condition you never had P = a condition you have had in the past Easy bleeding or bruising Anemia Deep leg pain Cold hands/feet Varicose veins Thrombophlebitis
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Male Reproduction Y = a condition you have now N = a condition you never had P = a condition you have had in the past Hernias Testicular masses Testicular Pain Prostate Disease Venereal disease Discharge or sores Are you sexually active? Gonorrhea Impotence Chlamydia Herpes Genital warts Syphilis
Female Reproduction/Breasts
Age of first menses? ______ Date of last annual exam/PAP? ____________________
Length of cycle? _________ Duration of menses?_______ Age of last menses (if menopausal)? _____
Y = a condition you have now N = a condition you never had P = a condition you have had in the past Painful menses Are cycles regular Clotting Spotting between cycles Heavy or excessive flow Pain during intercourse PMS Symptoms:___________________ Discharge Endometriosis Birth control Ovarian cysts Type: __________________ Difficulty conceiving Number of pregnancies _________________ Cervical Dysplasia Number of live births _________________ Sexual Difficulties Number of miscarriages _________________ Herpes Number of abortions _________________ Are you sexually active Menopausal symptoms _________________ Do you do breast self exams Abnormal PAP Chlamydia Genital warts Syphilis Breast lumps Breast pain/tenderness Nipple discharge
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Is there anything else you would like to comment on?
