Download PERSONAL HISTORY Last name: ……………………. First name

PERSONAL HISTORY
Last name: ……………………. First name: ………………………………… Date: ………………………………...
Address: ………………………………………………………………………………………………………………..
Telephone No.: (Home) ……………..... (Work) ……………………………. (Mobile) ……………………………...
I.D. Card No: …………………………. Fax No: ……………………E-mail Address: ……………………………...
Age: ……… Date of Birth: ………...... (dd/mm/yy) Gender: Female / Male
Blood Group: ……………………….
Weight: ……………………. Height: …………………….. Eye Color: …………… Race: ………………………….
Please circle one: Married / Separated / Divorced / Widowed / Single / Partnership
Please circle whichever applies: Live with: Spouse / Partner / Parents / Children / Siblings / Friends / Pets / Helper
Occupation: ……………………………. Hours per week: ………………….. Or Retired: ………………………….
Person to contact in emergency? Name: ……………………………………………. Tel No.: ……………………....
How did you hear about our clinic? ……………………………………………………………………………………
Has any other family members already been a patient at this clinic? If yes, please give the name(s) ………………....
…………………………………………………………………………………………………………………………..
CANCELLATION POLICY
We require at least 8 business hours notice if you want to cancel your scheduled appointment without incurring any
charges.
As each appointment is a personal session, it is our policy to charge a 50% fee for a late cancellation or missed appointment as
this time could have been allocated to someone else. In the case of a late cancellation, if we are able to fill the slot, then you
will not be charged.
If your health insurance company is being billed for your treatments, we will not bill them for any missed appointments or late
cancellations. You will be required to pay the bill yourself and you may, in turn, bill your insurance company directly, if you
wish to do so.
I understand that Dr. Lynn Lim is not a medical doctor and does not make any medical diagnosis nor provide medical
treatment. All therapies and advice given are based on natural healing principles. I consent to being treatment based on
these principles.
I have read and agree to the cancellation policy as stated above.
Signed: _______________________________
Date:
_______________________________
1
PLEASE FILL IN AS COMPLETELY AS POSSIBLE
HEALTH HISTORY QUESTIONNAIRE
SUCCESSFUL HEALTH CARE AND PREVENTIVE MEDICINE ARE ONLY POSSIBLE WHEN THE
PHYSICIAN HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND
EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE. PRINT
ALL INFORMATION AND MARK ANYTHING YOU DON’T UNDERSTAND WITH A QUESTION MARK.
MEDICAL HISTORY
Name and address of your primary physician:
Physician’s name: ________________________Address: _____________________________________________
What is the purpose of the visit? (Please explain in detail).
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. ___________________________________________________________________________________________
4. ___________________________________________________________________________________________
List any major illnesses you have had: ______________________________________________________________
When
was
your
most
recent
complete
physical
exam?
__________________________________________________
FAMILY HISTORY (check all that apply)
FATHER
MOTHER
BROTHER
SISTER
GRANDPARENTS
CHILD
Age (if living)
Health (G – good / P
– Poor)
Age at death (if
deceased)
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Epilepsy
Mental Illness
Asthma / Hay fever
/ Hives
Kidney Disease
Glaucoma
Tuberculosis
Others
Cause of Death
Anemia
CHILDHOOD ILLNESSES
Scarlet fever
Y
N
Diphtheria
Y
2
N
Rheumatic fever
Y
N
Mumps
Y
N
Measles
Y
N
German measles
Y
N
IMMUNIZATIONS
Polio
Tetanus shot
Measles/Mumps/Rubella
Y
Y
Y
N
N
N
Pertussis
Y
Diphtheria
Y
Other
__________________________________
N
N
HOSPITALIZATION AND SURGERY
What surgeries, operations, traumas, car accidents, etc. have you had?
________________________________ Year: ________ _____________________________ Year: _______
________________________________ Year: ________ _____________________________ Year: _______
Have you ever had full-body anesthesia (i.e. to remove tonsils, wisdom teeth, etc.?___________________________
Do you have breast implants? _______ Other surgical implants or prostheses?
_______________________________
Have you had elective surgery (tummy tuck, face-lift, burned off moles, liposuction, etc.)?_____________________
Do you have any metal or plastic inside your body (such as pins, clamps, plates, etc.)?_______________________
Do you have pierced ears or other body piercing? ____________________________________________________
Describe any scars on your body (major and minor ones):______________________________________________
ALLERGIES
Foods
Drugs
Environmental Allergens
MEDICATIONS
Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking
and how long you have taken them (including birth control pills, aspirin, pain medications, etc).
1)
7)
2)
8)
3)
9)
RECREATIONAL DRUGS
This is strictly confidential information. Do you currently use recreational drugs?
___________________________________
[Circle] (marijuana, cocaine, heroin, uppers, downers) Others: _______________ How Often?
________________________
Have you used recreational drugs in the past? ________________ If yes, for how long?
______________________________
LIFESTYLE
1.
Exercise – Do you exercise? YES / NO If yes, what kind & how often? ____________________________
2.
Caffeine - Caffeine intake: _______ per day ________ per week
3.
Alcohol - Alcohol intake: _______ per day ________ per week
4.
Cigarettes – Cigarette intake: _______ per day ________ per week
5.
Stress - Please rate your current stress level (on a scale of 1 to 10, 10 being the highest level):
____________________
What
is
the
main
reason
(s)
for
your
stress?
_____________________________________________________________
If over level 5, what step(s) are you taking to reduce your stress level? _
_____________________________________
6.
Sleep How is your sleep? [Cross: restless, hard to get to sleep, wake up often, get up during the night, bad
dreams.] Other complaints?
3
_________________________________________________________________________
What time do you usually go to sleep? _______________ Number of hours of sleep per night?
____________________
How much change are you willing to make at this time for improving your health?
MINIMAL
SOME
COMPLETE
REVIEW OF SYSTEMS
FOR THE FOLLOWING, PLEASE CIRCLE
Y = a condition you have now N = never had P = a condition you have had before
MENTAL / EMOTIONAL
Treated for emotional problems
Y
P
N
Depression
Y
P
N
Mood Swings
Y
P
N
Anxiety or nervousness
Y
P
N
Considered/Attempted suicide
Y
P
N
Tension
Y
P
N
Poor concentration
Y
P
N
Memory problems
Y
P
N
ENDROCRINE
Hypothyroid
Y
P
N
Heat or cold intolerance
Y
P
N
Hypoglycemia
Y
P
N
Diabetes
Y
P
N
Excessive thirst
Y
P
N
Excessive hunger
Y
P
N
Fatigue
Y
P
N
Seasonal depression
Y
P
N
IMMUNE
Vaccinations
Y
P
N
Reactions to vaccinations
Y
P
N
Chronic Fatigue Syndrome
Y
P
N
Chronic infections
Y
P
N
Chronically swollen glands
Y
P
N
Slow wound healing
Y
P
N
NEUROLOGIC
Seizures
Y
P
N
Paralysis
Y
P
N
Muscle weakness
Y
P
N
Numbness or tingling
Y
P
N
Loss of memory
Y
P
N
Easily stressed
Y
P
N
Vertigo or dizziness
Y
P
N
Loss of balance
Y
P
N
SKIN
Rashes
Y
P
N
Eczema / Hives
Y
P
N
Acne / Boils
Y
P
N
Itching
Y
P
N
Color change
Y
P
N
Perpetual hair loss
Y
P
N
Lumps
Y
P
N
Night sweats
Y
P
N
4
HEAD
Headaches
Y
P
N
Head Injury
Y
P
N
Migraines
Y
P
N
Jaw / TMJ problems
Y
P
N
EYES
Spots in the eyes
Y
P
N
Cataracts
Y
P
N
Impaired vision
Y
P
N
Glasses or contacts
Y
P
N
Blurriness
Y
P
N
Eye pain / strain
Y
P
N
Color blindness
Y
P
N
Tearing / dryness
Y
P
N
Double vision
Y
P
N
Glaucoma
Y
P
N
EARS
Impaired hearing
Y
P
N
Ringing
Y
P
N
Earaches
Y
P
N
Dizziness
Y
P
N
NOSE AND SINUSES
Frequent colds
Y
P
N
Nose bleeds
Y
P
N
Stuffiness
Y
P
N
Hayfever
Y
P
N
Sinus problems
Y
P
N
Loss of smell
Y
P
N
NECK
Lumps
Y
P
N
Swollen glands
Y
P
N
Goiter
Y
P
N
Pain / Stiffness
Y
P
N
BLOOD/PERIPHERAL VASCULAR
Easy bleeding or bruising
Y
P
N
Anemia
Y
P
N
Deep leg pain
Y
P
N
Cold hands
Y
P
N
Varicose veins
Y
P
N
Thrombophlebitis
Y
P
N
MOUTH AND THROAT
Frequent sore throat
Y
P
N
Copious saliva
Y
P
N
Teeth grinding
Y
P
N
Sore tongue / lips
Y
P
N
Gum problems
Y
P
N
Hoarseness
Y
P
N
Dental cavities
Y
P
N
Jaw clicks
Y
P
N
RESPIRATORY
Cough
Y
P
N
Sputum
Y
P
N
Spitting up blood
Y
P
N
Wheezing
Y
P
N
Asthma
Y
P
N
Bronchitis
Y
P
N
Pneumonia
Y
P
N
Pleurisy
Y
P
N
5
Emphysema
Y
P
N
Difficulty breathing
Y
P
N
Pain on breathing
Y
P
N
Shortness of breath
Y
P
N
Shortness of breath at night
Y
P
N
Shortness of breath when lying down
Y
P
N
Tuberculosis
Y
P
N
CARDIOVASCULAR
Heart disease
Y
P
N
Angina
Y
P
N
High/Low Blood Pressure
Y
P
N
Murmurs
Y
P
N
Blood clots
Y
P
N
Fainting
Y
P
N
Phlebitis
Y
P
N
Palpitations/Fluttering
Y
P
N
Rheumatic Fever
Y
P
N
Chest Pain
Y
P
N
Swelling in ankles
Y
P
N
Y
P
N
GASTROINTESTINAL
Trouble swallowing
Y
P
N
Heartburn
Y
P
N
Change in thirst
Y
P
N
Change in appetite
Y
P
N
Nausea
Y
P
N
Vomiting
Y
P
N
Vomiting blood
Y
P
N
Bowel movements: How often?
Blood in stool
Y
P
N
Is this a change?
Y
P
N
Pain / Cramps
Y
P
N
Constipation
Y
P
N
Belching / Passing gas
Y
P
N
Diarrhea
Y
P
N
Black stools
Y
P
N
Gall Bladder disease
Y
P
N
Jaundice
Y
P
N
Ulcer
Y
P
N
Liver Disease
Y
P
N
Hemorrhoids
Y
P
N
URINARY
Pain on urination
Y
P
N
Increased frequency
Y
P
N
Frequency at night
Y
P
N
Inability to hold urine
Y
P
N
Frequent infections
Y
P
N
Kidney stones
Y
P
N
MUSCULOSKELETAL
Joint pain / stiffness
Y
P
N
Arthritis
Y
P
N
Broken bones
Y
P
N
Weakness
Y
P
N
Muscle spasms / cramps
Y
P
N
Sciatica
Y
P
N
MALE REPRODUCTIVE
Hernias
Y
P
N
Syphilis
Y
P
N
Testicular pain
Y
P
N
Prostate disease
Y
P
N
Venereal disease
Y
P
N
Discharge or sores
Y
P
N
Are you sexually active?
Y
N
Chlamydia
Y
P
N
6
Birth control? Type:
Y
P
N
Gonorrhea
Y
P
N
Impotence
Y
P
N
Condyloma
Y
P
N
Premature ejaculation
Y
P
N
Herpes
Y
P
N
Testicular masses
Y
P
N
REVIEW OF HORMONE
Please check () any symptoms that apply to you..
Thyroid hormone
Thyroid Deficiency
Thyroid Excess or Overdose
Fatigue
Fatigue
Weight gain
Anxiety
Chilliness
High measured body temperature
Low measured body temp
Tremor
Fluid retention
Perspiration
Constipation
Heart palpitations
Hair becoming coarser
Elevated cholesterol
Dry skin
Hoarseness
Mental slowness
Yellow tinged skin
Melatonin
Melatonin Deficiency
Melatonin Overdose
Insomnia
Drowsiness in morning
Shift work
Tendency to be easily over-heated
A n d r o g e n s (testosterone)
Androgen Deficiency
Androgen Excess
Decreased energy
Acne
Decreased well-being
Irritability
Decreased sex drive
Abdominal weight gain
Thinning public hair
Male pattern baldness
Decreased muscle mass
High blood sugar
Low bone density
Elevated cholesterol
Softer erection
High blood pressure
A d r e n a l hormones
7
Cortisol Deficiency
Cortisol Excess or Overdose
Morning fatigue
Low bone density
Sugar craving
Skin fungal infections
Allergies
Thinning skin
Chemical sensitivity
High blood sugar
Chilliness
Round (moon) face
Arthritis
Fluid retention
Low blood pressure
Abdominal weight gain
Frequent infections
Fine downy face hair
Darkened skin
Pigmented scarring
Adrenal hormones
DHEA Deficiency
DHEA Overdose
Chronic, severe fatigue
Testosterone excess (above)
Poor recovery from stress
Inflammation
Autoimmune disorders
Low bone density
Testosterone deficiency (above)
Additional information:
8