Download General Information

General Information
Name_____________________________________________ Age______ Today’s
Date____________
Date of Birth_________________________
Email__________________________________________________
Address___________________________________ City___________________ State______
Zip_________
Phone (Home) _____________________ (Cell)______________________
(Work)__________________
Genetic Background:

Caucasian
African American
Hispanic
Mediterranean
Asian
Native American
European
Other____________________________________________________________________
When, where and from who did you last receive medical or health care?
____________________________________________________________________________
Emergency Contact:_ __________________________________________________________
Relationship_________________________
Phone (Home)___________________ (Cell)_____________________
(Work)___________________
How did you hear about our practice?
Clinic website
Referral from doctor
Referral from friend/family member
Social media
Other____________________________________________________________________
Current Health Concerns
Please rank current and ongoing health concerns in order of priority
Description of
problem
Example: eczema
1.
2.
3.
4.
5.
Mild
Moderate
x
Severe
Prior Treatment
approach and
outcome
Excellent
Good
Fair
Steroid cream
x
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Health Goals
When was the last time you felt well?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What makes you feel better?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What makes you feel worse?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
How does your condition affect you?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Did something trigger your change in health?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What do you feel needs to happen for you to get better?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Are there things that stop you from making the necessary changes to feel better?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What do you hope to achieve in your visit with us?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Current occupation:
____________________________________________________________________________
Previous occupations:
____________________________________________________________________________
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Readiness Assessment and Health Goals
Rate on a scale of 5 (very willing) to 1 (not willing):
In order to improve your health, how willing are you to:
Significantly modify your diet
Take several nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (e.g. sleep habits)
Practice a relaxation technique
Engage in regular exercise
5 4 3 2 1 
5 4 3 2 1 
5 4 3 2 1 
5 4 3 2 1 
5 4 3 2 1 
5 4 3 2 1 
Rate on a scale of 5 (very supportive) to 1 (very unsupportive):
At the present time, how supportive do you think the people in your household will be to
your implementing the above changes?
5 4 3 2 1 
Lifestyle Review
Sleep
How many hours of sleep do you get each night on average?
____________________________________
Do you have daytime sleepiness?
Yes No 
Do you have problems falling asleep?
Yes No 
Do you have problems staying asleep?
Yes No 
Do you have problems with insomnia?
Yes No 
Do you snore?
Yes No 
Do you feel rested upon awakening?
Yes No 
Do you use sleeping aids?
Yes No 
If yes, explain:_________________________________________________________________
Do you have sleep apnea?
Yes No 
If yes, do you use CPAP routinely?
Yes No 
Exercise
Do you currently exercise:
Yes  A little  No 
Current Exercise Program:
Do you feel motivated to exercise?
Yes  A little  No 
Are there any problems that limit exercise? Yes No 
If yes, explain:_________________________________________________________________
Do you feel unusually fatigued or sore after exercise? Yes No 
If yes, explain:_________________________________________________________________
Nutrition
Do you currently follow any of the following special diets or nutritional programs? (Check all that
apply)
Vegetarian
Vegan
Allergy
Elimination
Low Fat
Low Carb
High Protein
Blood Type
Gluten Free
No Dairy
No Wheat
Low sodium
Other:____________________________________________________________________
Do you have sensitivities to certain foods? Yes No 
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If yes, list food and symptoms:
____________________________________________________________________________
Do you have any food allergies?
Yes No 
If yes, list foods:
____________________________________________________________________________
Are there any foods that you crave or binge on? Yes No 
If yes, what foods?
____________________________________________________________________________
Do you eat 3 meals a day?
Yes No 
If no, how many meals per day do you eat?
____________________________________________________________
Any lifestyle or other barriers to healthy eating?
Yes No 
If yes, please explain:
___________________________________________________________________
Cans of soda (regular or diet) ______
Number of glasses of water per day: 1-2
3-4
5-6
7-8
>8
Stress
Do you feel you have an excessive amount of stress in your life?
Yes No 
Do you feel you can easily handle the stress in your life?
Yes No 
How much stress does each of the following cause on a daily basis (Rank on scale of 1-10, 10
being highest)
Work_____ Family_____ Social_____ Finances_____ Health_____ Other_____
Do you use relaxation techniques? Yes No 
If yes, how
often?______________________________________________________________________
Which techniques do you use? (Check all that apply)
___Meditation ___Breathing ___Tai Chi ___Yoga ___Prayer
___Other:____________________________________________________________________
Have you ever sought counseling? Yes No 
Have you ever been abused, a victim of crime, or experienced a significant trauma?
Yes No 
What are your hobbies or leisure activities?__________________________________________
Do you have resources for emotional support? Yes No 
(Check all that apply)
___Spouse/Partner ___Family ___Friends ___Religious/Spiritual ___Pets
___Other:________________
Do you have a religious or spiritual practice? Yes No 
If yes, what kind? ______________________________________________________________
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Relationships
Marital status: ___Single
___Long-Term Partner
___Married ___Divorced ___Gay/Lesbian
___Widow/er
With whom do you live? (Include children, parents, relatives, friends, and pets)
____________________________________________________________________________
History
Patient’s Birth/Childhood History:
You were born: ___Term ___Premature ___Don’t know
Were there any pregnancy or birth complications? Yes No 
If yes, explain:_________________________________________________________________
You were: ___Breast-fed
___Don’t know
___Bottle-fed
As a child, were there foods you avoided because they gave you symptoms? Yes No 
If yes, what foods and what symptoms? (Example: milk—gas and diarrhea)
____________________________________________________________________________
____________________________________________________________________________
Dental History:
Check if you have any of the following:
___Silver mercury fillings
___Gold fillings
___Caps/Crowns
___Tooth pain
___Root canals
___Bleeding gums
___Implant
___Gingivitis
Have you had any mercury fillings removed? Yes No 
If yes, when: _____________________________
Environmental/Detoxification History
Do any of these significantly affect you?
Cigarette smoke
Perfume/colognes Auto exhaust fumes
Other___________________
Current or historical exposure to: (Check all that apply)
___Mold
___Water leaks
___Damp environments
___Renovations
___Carpets or rugs ___Paints
___Pesticides
___Herbicides
___Cleaning chemicals
___Heavy metals (lead, mercury, etc.)
___Harsh chemicals (solvents, glues, gas, acids, paint thinner, etc.)
Have you had a significant exposure to any harmful chemicals?
Yes No 
If yes: Chemical name, length of exposure, date:_____________________________________
Any significant exposure to mold? Yes No 
Do you have any pets or farm animals?
Yes No 
If yes, do they live: ___Inside
___Outside  ___Both
What kind of pet:___________
Did you grow up on a farm or city? ________________________________________________
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Tobacco and Alcohol History
Currently use tobacco products?
Yes No 
If yes, what kind? ______________________________________________________________
If you have quit, what was your quit date? __________________________________________
Current alcohol use?
Yes No 
If yes, number of servings per week?1-2 3-4
Other
History of tick bites or tick exposure?
If yes, did you have any rash?
Were you ever treated with antibiotics?
What state did tick bite occur? ____________
5-6
7-8
>8
Yes No 
Yes No 
Yes No 
Antibiotic history:
>5 times as a child: Yes No 
> 5 times as a teen: Yes No 
>5 times as an adult:Yes No 
Steroid history:
>5 times as a child: Yes No 
> 5 times as a teen: Yes No 
>5 times as an adult: Yes No 
Routine non-steroidal anti-inflammatory use like motrin, advil or alieve:
Routine acid blocker use like zantac, Prilosec, protonix, omeprazole:
Immunosuppression therapy: Yes No 
Yes No 
Yes No 
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Women’s History
Obstetric History: (Provide number if applicable)
 Pregnancies____ 
Abortions_____
Living children_____
 Vaginal deliveries____
Cesarean____
Term births____
 Premature birth____
Birth weight of largest baby_______________ Birth weight of smallest baby_______________
Menstrual History:
Age at first period_______ Date of last menstrual period______________________
Irregular periods:
Yes No 
Painful menses:
Yes No 
Heavy bleeding:
Yes No 
Post-menopausal bleeding: Yes No 
Painful intercourse:
Yes No 
Low libido:
Yes No 
Urinary leakage:
Yes No 
Breast tenderness:
Yes No 
PMS symptoms:
Yes No 
Hot flashes:
Yes No 
Night sweats:
Yes No 
Mood swings:
Yes No 
Vaginal dryness:
Yes No 
Ovarian cysts:
Yes No 
Sexually transmitted disease: Yes No  If yes, what type?__________________
Hysterectomy: Yes No 
Ovaries retained: Yes No 
Cervix present: Yes No 
Miscarriages: Yes No 
Past oral contraceptive use:
Yes No 
Date of last Digital
rectal exam: _____
Past hormone replacement: Yes No 
History of abnormal pap: Yes No 
History of abnormal mammogram:
Yes No 
History of gestational diabetes or baby > 8lbs:
Yes No 
History of infertility: Yes No 
Personal history of
Cancer:
Yes No 
Self-Breast Exam:
Yes No 
Gynecological Screening/Procedures: (If applicable, provide date)
Last Pap test: ______________________ Results:
Normal Abnormal 
Last mammogram: __________________ Results:
Normal Abnormal 
Last bone density: ___________________ Results:
Normal Abnormal 
Last colonoscopy: ___________________ Results:
Normal Abnormal 
Performed by whom: __________________________
Other tests/procedures (list type and dates)
____________________________________________________________________________
____________________________________________________________________________
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Men’s History
(Check box if applicable)
Testicular mass  
Testicular pain 

Prostate enlargement  
Prostate infection 
Change in sex drive  Loss of control of urine 
Vasectomy 

Difficulty obtaining or maintaining an erection  

Urinary urgency/hesitancy/change in stream  

Nocturia (urination at night) # of times per night________________
Sexually transmitted disease: Yes No  If yes, what type?_______________________
Do you perform Self-Testicular exams?
Yes No 
Screening/Procedures: (If applicable, provide date)
Last PSA test: ______________________ PSA Level: 0-2 2-4 4-10 >10 
Last colonoscopy: ___________________ Results: Normal Abnormal 
Performed by whom: __________________________
Other tests/procedures (list type and dates, i.e. Bone density)
____________________________________________________________________________
____________________________________________________________________________
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Medications
Dose
Frequency
Reason for taking
Supplements
Dose
Frequency
Reason for taking
Allergies: Foods, meds, supplements
Reactions
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