Health Survey

The purpose of this form is to provide me with as much information as possible about your overall health. All the information you disclose will be treated with absolute confidentiality. Please be as complete in your answers as possible; each piece of information is important in assembling a comprehensive picture of your health.

Thank you for taking the time to fill out this form.

Name*

Age

Address (Please include Street, City, State & ZIP)

E-mail address

Phone (w/area code)

Do you wish to be on our mailing list?

Please list the 3 major health concerns in order of importance:

Family Medical History

Cancer
Heart Trouble
Kidney Disease
Liver Disease
Spinal Problems
Diabetes
TB
Epilepsy
Ulcers
Arthritis
Mental Disorders
High or Low Blood Pressure
Allergies
Asthma
Sinus Problems
Alcoholism
Drug Addiction
Other

Age Parents Died: Mother   Father

Personal Medical History

(include dates of major surgeries, illnesses, diseases, accidents)

Contagious Diseases

(check if you have ever had one of the following)

HIV
Aids
Hepatitis
Venereal Disease
Herpes
Other

Allergies-Known or Suspected

(drugs, chemicals, food, animals, seasonal, etc.)

Current Medications

(include prescriptions, vitamins, herbs, etc.)

Health Habits

No Yes — Frequency

No Reg Decaf — Frequency

No Reg Decaf — Frequency

No Wine Beer Liquor — Frequency

No Regular Diet — Frequency

No Yes — Frequency

Daily Water Intake: ounces

Do you have an adequate energy level? (Y/N)

Mark the stress level in your life: (0=No stress, 10=Tremendous stress)

What is your job satisfaction? (0=Unsatisfied, 10=Satisfied)

How many hours per week do you work?

How many hours per week do you have free time?

Tendency towards:
sadness/depression
anger/irritability
anxiety/fear
mental over-activity

Diet - Please describe a typical day's diet:

Are you on any type of diet presently? (describe)

Do you feel good about your weight? (would you like to gain or lose weight?)

Have you recently experienced a significant weight change?

Do you know your blood type?

Digestion

Indigestion
Heartburn
Gurgling stomach
Bitter taste in mouth
Hepatitis/liver trouble
Lump in throat
Nervous stomach
Nausea/Vomiting
Abdominal pain/cramps
Gallstones/gallbladder disease
Difficulty digesting fatty foods
Difficulty swallowing
Bloating/gas in lower abdomen
Frequent belching
Bad breath
Ulcers

Bowels

Loose stool
Diarrhea
Constipation
Black stool
Intestinal worms
Burning anus
Blood in stool
Hemorrhoids
Anal itch
Hard or difficult BM
Small amount of stool
Undigested food in stool
Stool with bad smell
Mucus in stool
Painful bowel movement
Use laxatives

Urination

Frequent
Night-time
Incontinence
Cloudy
Urgent
Pus
Abnormal color
Burning/painful
Scanty
Profuse
Bladder infections
Kidney stones/infections
Blood in urine
Slow or straining to urinate
Strong smell

Thirst

Rarely thirsty
Always thirsty
Thirsty, but do not drink
Always drink cold beverages
Always drink hot beverages

Sleep

Difficulty falling asleep
Awakened easily
Difficulty falling back to sleep
Tired when getting up in the morning
Sleep too much
How many hours per night do you sleep?

Headaches / Dizziness

Headaches
Motion sickness
Poor memory
Head feels heavy
Poor balance
Get dizzy when bending down then standing
Vertigo
Faint easily
Dizzy/lightheaded
Migraines

Skin

Dry
Oily
Nail fungus/infection
Rashes/hives
Eczema/psoriasis
Hives
Clammy
Pimples
Brittle/weak nails
Warts
Strong body odor
Boils
Bruise easily
Cuts heal slowly
Itching
Non-healing sore
Premature gray hair
Herpes:
   lips
   genital
   zoster (shingles)

Eyes

Wear glasses/contacts
Cataracts
Spots or lines in vision
Poor night vision
Sensitive to light
Blurry vision
Dry
Yellow
Failing vision
History of sties
Double vision
Glaucoma
Blinking
Twitching
Swollen eyelids
Inflamed eyes
Itching
Painful
Strained
Red
Tear easily

Ears

Poor hearing
Ear aches
Excessive wax
Blood/pus discharge
Ringing/buzzing

Nose

Runny nose/discharge
Nosebleeds
Chronic sinus trouble
Loss of Smell
Stuffy nose
Hay fever
Sneeze a lot
Snoring

Mouth and Throat

Dry mouth
Gum problems
Teeth problems
Frequent colds
Mouth/tongue sores
Frequent sore throats
TMJ pain
Dry cracked lips
Thyroid problems
Swollen glands
Hiccups
Hoarseness
Grind teeth

Body Temperature

Easily chilled
Feel cold after eating
Cold hands and feet
Feel warm or hot
Sweat easily
Sweat or too warm while sleeping

Respiratory

Shortness of breath
Dry cough
Bronchitis
Tightness in chest
Sigh a lot
Cough with phlegm
Cough with blood
Emphysema
Pain with breathing
Asthma
Chronic cough

Cardiovascular / Circulation

Diagnosed heart problems
Bleed easily
Heart murmur
Broken blood vessels
Irregular beat/palpitations
Rheumatic fever
High cholesterol
Purple palms
Varicose veins
Chest pain/angina
Low blood pressure
High blood pressure
Swelling of hands/feet/ankles
Slow heart rate
Numbness in extremities

Pain

Low back
Sciatica
Upper back
Mid back
Neck
Spine
Shoulder
Hands or wrists
Hips
Knees
Feet or ankles
Arthritis
Muscle weakness
Muscle cramps
Muscle twitching/spasm
Pain in damp weather
Nerve
Flank Area

For Men Only

Reduced sex drive
Prostate problems
Difficulty in starting stream of urine
Impotence
Pain/burning upon urination
Discharge
Genital pain
Dribbling of urine

For Females Only

Are you or might you be pregnant? (Yes / No / Maybe)

Approximate date of conception

How often do you have PAP tests?
If abnormal, when?

How often do you have breast exams?
If abnormal, when?

Do you have excessive facial or body hair? (Yes / No)

Are you experiencing reduced sex drive? (Yes / No)

Menstrual Cycle

Age started: Days of flow: Age begun menopause:

Days from the beginning of your period to the start of your next period:

Irregular
Scanty flow
Dark color flow
Constipation
Tender breasts
Emotional changes
Painful
Water retention
Light color flow
Diarrhea
Abdominal bloating
Spotting between periods
Heavy flow
Backache
Clotting
Tightness in chest
Breast lumps

Vaginal Discharge

Yellow
White
Thick
Clear
Bad odor
Itching

Menopause Problems

Please describe any problems you are experiencing

Pregnancies

Total number

Number of children

Number of miscarriages

Number of therapeutic abortions

Describe any problems with your pregnancies, especially any that resulted in termination.

Gynecological History and Operations

(please check and explain where applicable)

Ovaries Yes No

Uterus Yes No

Fallopian Tubes Yes No

Vagina Yes No

Breasts Yes No

DES exposure Yes No

What method of birth control do you now use?

What method(s) of birth control have you used in the past?

Please be patient.
It may take a moment to process this information.