Download Patient vital intake questionnaire form

Dr. David M. Thayer, DC, FIAMA, Dipl. Ac.
Board Certified Acupuncture, Auriculotherapy, and Chiropractic
PATIENT VITAL INTAKE [HQ] HEALTH QUESTIONAIRE
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Patient Name
________/________/________
Birthdate
___________
Age
_______________________
Home Phone
___________________
Height
__________________
Weight
_______________________
Work Phone
_______________________
Cell Phone
Complaints:
How long has it been occurring?
Treatment/Palliative action (What makes it feel better)?
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Please list all surgeries, traumas, medications, and allergies. Give dates, age of occurrences, or years as best as you can remember.
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Family Medical History
O Obesity
O Diabetes
O Stroke
O Heart Disease
O Seizures
O High Blood Pressure
O Other Diseases / Cancer (explain below)
Your Habits
O
O
O
O
O
O
Cigarettes
Marijuana
Unprescribed Drugs
Coffee
Bitter Chocolate
Sugar
O Alcohol
Drinks Per Week: _____
O Occasionally
O Often
Frequency:
Please explain: ______________________________________________________________________
O Tea
O Carbonated Beverages
Cups/Glasses/Cans per day: _____________
O Sweet Chocolate
O Artificial Sweetener
O Salt
Please explain any cravings or any other items you feel are important that we know:
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General Issues
O
O
O
O
O
O
O
Poor Appetite
O Heavy Appetite
Insomnia
O Fatigue
Cold Hands
O Cold Feet
Fevers
O Chills
Cravings
O Localized Weakness
Sudden Energy Drops (Time?) ____________
Strong Thirsts (cold/hot drinks) ____________
O
O
O
O
O
O
O
Poor Sleep
O Heavy Sleep
Tremors
O Vertigo
Cold Back
O Cold Abdomen
Night Sweats
O Sweat Easily
Poor Coordination
O Changes in Appetite
Peculiar Tastes/Smells (explain?) _____________________________
Bleed / Bruise Easily (where?) _______________________________
Skin / Hair
O Rashes
O Ulcerations
O Eczema
O Pimples
O Change in Hair/Skin Texture
O Hives
O Dandruff
O Purpua
O Itching
O Loss of Hair
O Other hair/skin issues (explain below)
Head / Eyes / Ears / Nose / Throat
O Dizziness
O Concussions
O Migraines
O Wear Corrective Lenses
O Eye Strain
O Eye Pain
O Poor Vision
O Night Blindness
O Color Blindness
O Cataracts
O Blurry Vision
O Earaches
O Ringing in Ears
O Poor Hearing
O Nose Bleeds
O Sinus Problems
O Mucus
O Dry Throat
O Dry Mouth
O Copious Saliva
O Teeth Problems
O Jaw Clicks
O Grinding Teeth
O Facial Pain
O Gum Problems
O Spots in Eyes
O Recurrent Sore Throats (how many times per month?)_____________
O Sores on Lips or Tongue
O Headaches (where and when?)
O Other Head / Neck Problems ______________________________________________________________________________
PATIENT VITAL INTAKE [HQ] HEALTH QUESTIONAIRE
Cardiovascular
O High Blood Pressure
O Dizziness
O Blood Clots
O Low Blood Pressure
O Fainting
O Phlebitis
O Chest Pain
O Cold Hands / Feet
O Difficulty Breathing
O Irregular Heartbeat
O Swelling in Hands / Feet
O Other
Respiratory
O Cough
O Coughing Blood
O Asthma
O Bronchitis
O Pneumonia
O Difficulty in Breathing When Lying Down
O Tight Chest
O Production of phlegm: Frequency? (daily, hourly, etc.) _______________ What Color? _______________
Gastrointestinal
O Nausea
O Gas
O Bad Breath
O Constipation
O Pain or Cramps
O
O
O
O
O
Gastro-Urinary
O Pain at Urination
O Unable to Hold Urine
O Wake Up to Urinate
O Frequent Urination
O Blood in Urine
O Kidney Stones
O Venereal Disease
How Often? ______/night; times: _______________
Vomiting
O Diarrhea
Belching
O Black Stool
Rectal Pain
O Hemorrhoids
Bloody Stools
O Sensitive Abdomen
Laxative Use: ____times/wk. type: ____________
Pregnancy and Gynecology
O # of Pregnancies: _______ O Number of Births: _______
O Age at First Menses: _____ O Period Length: _______ days
O Flow (describe below)
O Clots
O Vaginal Discharge
O Vaginal Sores
O Birth Control: Type: _____________ Duration: ___________
Musculoskeletal
O Neck Pain
O Muscle Pains
O Other Joint or Bone Problems?
O
O
O
O
O
BOWEL MOVEMENTS
Frequency:
_____________
Color:
_____________
Odor:
_____________
Texture/Form:
_____________
O Urgency to Urinate
O Impotency
O Other Gastro-Urinary Problems
Premature Births: _______ O Miscarriages: ____________
Duration: ______________ O Irregular Periods: _________
Last PAP: _____________ O Last Menses: ____________
Breast Lumps
O Menopause: _____________
Changes in Body / Psyche prior to Menstruation?
O Back Pain (where?)
Neuropsychological
O Seizures
O Areas of Numbness
O Poor Memory
O Depression
O Anxiety
O Bad Temper
O Treated for emotional problems (explain below)
O Other neurological or psychological problems? (explain below)
O Joint Pains (where?)
O Concussion
O Easily Stressed
O Considered/Attempted Suicide
Classical
PREFERENCE
Season
Taste
Climate
Time of Day
Temperature
MOST LIKED
LEAST LIKED
Body Type
Color
Tone
Yin/Yang
Firm/Weak
Hot/Cold
Surface/Interior
I certify that the above accurately describes my symptoms as of the date of this form:
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Signature of Patient
Date