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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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