Download Medical History - Grand Rapids Natural Health

Grand Rapids Natural Health, LLC
638 Fulton St W Suite B
Grand Rapids, MI 40504
T (616) 264-6556
www.grnaturalhealth.com
F (616) 432-3564
GRAND RAPIDS NATURAL HEALTH INITIAL PAPERWORK
Patient Name
Age
Address
City
Daytime Phone
Occupation
Date of Birth
State
Evening Phone
Cell Phone
Employer
Email Address:
Emergency Contact:
/
Phone:
How did you hear about us?
Reason for visit
today?
Primary Health Concerns: (In order of importance)
1.
2.
3.
4.
Medical History
Allergies: (Medications, Food, Environmental)
Please list Past Surgeries and/or Hospitalizations:
1)
Date:
2)
Date:
3)
Date:
/
Sex: F M
Zip
Please List the Medications you are currently taking: (with dosage)
1)
2)
3)
4)
5)
Primary Care Screening Exams: When was your last-

Last Eye exam:

Last Dental exam:

Last Pap and Mammogram:

Last DEXA:

Last DRE:

Last Blood work:
Please list the supplements you are taking: (with dosage)
1)
2)
3)
4)
5)
Family History
Please list any significant health concerns for the following relatives.
Age (if alive)
Father
Mother
Siblings
Maternal
Grandfather
Grandmother
Aunts/Uncles
Age(at death)
Health Problems
Paternal
Grandfather
Grandmother
Aunts/Uncles
Social History
Food allergies:
Drug allergies:
What happens:
What happens:
Use of the following (circle what applies and write C for current use, P for past use, and indicate how much):
Cigarettes
Recreational drugs
Alcohol
Other
Water Intake in ounces daily
Sleep: Circle all that apply:
Coffee (cups/day)
Difficulty falling asleep
Waking Frequently
Waking unrefreshed
Bowel Movements: Number per day
Circle all that apply: Undigested food Mucous
Exercise: Frequency/week
Types:
Personal Birth History: Circle one:
Vaginal Birth/C-section
Blood
Breast fed/Formula fed
Approximate Rounds of Antibiotics Taken in Lifetime:
Review of Systems
Please mark now (W) or past (P) next to all areas that apply to your past and present health.
HEENT
headaches
dizziness
blurry vision
fainting/blackouts
loss of balance
eye pain/red eye
cataracts/glaucoma
Chest
wheezing
cough up blood
heart palpitations
Gastrointestinal
stomach pain
indigestion
nausea
blood in vomit
yellow skin/jaundice
earaches
ringing in ears
difficulty hearing
nosebleeds
loss of smell
hoarse voice
grinding teeth
neck lumps/swelling
dental problems
sore throat
sore/bleeding gums
difficulty swallowing
cold or canker sores
high blood pressure
swollen ankles
chest pain
shortness of breath
chest colds
chest pain
constipation
diarrhea
vomiting
gas/bloating
clay colored stool
loss of appetite
excessive appetite
blood in stool
light colored stool
rectal pain/itching
Genitourinary
frequent urination
urge to urinate
incontinence
difficulty urinating
Musculoskeletal
aching muscles
numbness/tingling
restless legs
blood in urine
kidney stones
sexual difficulty
pain with urination
bladder infections
genital sores
STDs
genital discharge
broken bones
weakness
swollen joints
sore joints
leg cramps
tender point
Skin
acne
itching
Endocrine
always cold
always hot
rashes
lesions
easy bruising
hives
chronic fatigue
weakness
increased hunger
increased thirst
Nervous
anxiety
loss of sensation
tremor
foggy thinking
lack of strength
convulsions
loss of memory
lack of concentration
paralysis
Blood, Immune
painful lymph nodes
frequent bleeding
anemia
fluid retention
swollen glands
wounds heal slowly
Male Reproductive
prostrate problems
painful erections
painful urination
infertility
discharge
difficult/premature
ejaculation
swelling in testicles
Female Reproductive
lumps in breast(s)
breast pain
missed periods
lack of sexual desire
pelvic pain
Mental/emotional
depressed mood
suicidal thoughts
angered easily
afraid of being alone
shy/timidity
vaginal discharge
heavy periods
genital eruptions
pain with intercourse
vaginal itching/burning
restlessness
excessive worry
loneliness
critical of others
scary dreams
painful testicles
trouble maintaining
erection
spotting between
periods
difficulty having
orgasms
mental confusion
mood swings
frequent crying
suspicious/jealous
confident/secure