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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 whichever applies: Live with: Spouse / Partner / Parents / Children / Siblings / Friends / Pets / Helper 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 PATIENT QUESTIONAIRE PRESENT HISTORY 1) Main symptoms 2) When did first symptom occur 3) Did symptom first occur in infancy, childhood, adolescence or adult 4) Did symptom first occur after going through a certain procedure (dental, antibiotic treatment, vaccination, etc) 5) Did symptom first occur after a bout of illness 6) Did symptom first occur after a change in diet 7) Did symptom first occur after a change in living environment 8) Did symptom first occur after a change in family dynamics 9) How often does the symptom occur in a day/month/year 10) What time of the day/month/year does the symptom occur 11) What makes the symptom worse 12) What makes the symptom better PRENATAL HISTORY 1) Parental Exposures (tick () whichever applies) 1. Cadmium, Lead, Mercury 2. Excessive intake of caffeine, alcohol 3. Carbon dioxide poisoning 4. Bacterial toxins, chemicals toxins (including drugs intake) 5. Emotional traumas during fetal development (please explain) 2) Birth Records Delivery (normal, c-section, forceps, vacuum, etc) Birth Weight & Height APGAR Scores 2 GROWTH & DEVELOPMENT HISTORY A) Illn ess durin g ea rly infancy (ti ck ( ) as man y as app licab le): 1) Colic 2) Constipation 3) Diarrhea 4) Feeding problem 5) Excessive vomiting 6) Excessive white coating on the tongue 7) Excessive crying 8) Poor sleep 9) Disturbed sleep 10) Frequent ear infection 11) Frequent fever 12) Immunizations 13) Response to immunizations 14) Common childhood diseases (measles, chickenpox, mumps, strep-throat) 15) Any other unusual events (fire in the house, accidents, earthquakes, etc) B) Development Milestones – indicate the age 1) Walked alone 2) Talked 3) Toilet trained for bladder and bowel 4) Enrolled in school C ) M e d i c a l H i s t o r y (check ( ) as many as applicable) 1) Surgeries 2) Hospitalizations 3) Diseases 4) Allergies 5) Frequent colds 6) Fevers 7) Ear infections 8) Asthma 9) Hives 10) Bronchitis 11) Pneumonia 12) Seizures 13) Headaches 14) Vomiting 15) Diarrhea 16) Current medication 17) Any reaction to medication 18) Antibiotics 19) Other drugs 20) Parasitic 21) Visited other countries 22) Others.... 3 D) Social History – Describe wherever applicable 1) Grades at school 2) Interaction between friends and teachers 3) Interaction between family members 4) Activities at school 5) Phobias 6) Problems with discipline 1 ) B e h a v i o r s (check () as many as applicable) 1) Often does not seem to listen when spoken to directly 2) Often have difficulty organizing tasks and activities 3) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) 4) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) 5) Is often easily distracted by extraneous stimuli 6) Often has difficulty sustaining attention in tasks or play activities 7) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties (not due to oppositional behavior or failure to understand instructions) 8) Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities 9) Temper tantrums 10) Often leaves seat in classroom or in other situations which remaining seated is expected 11) Often runs about or climbs excessively in situation which it is inappropriate 12) Often fidgets with hands or feet or squirms in seat 13) Often talks excessively 14) Often has difficulty playing or engaging in leisure activities quietly 15) Is often “on the go” or often acts as if “driven by a motor” 16) Low self-esteem 17) Short attention span 18) Often blurts out answers before questions have been completed 19) Often has difficulty awaiting turns 20) Often interrupts or intrudes on others (e.g., butts into conversations or games) 21) Poor memory 22) Unusual fears 23) Falls down often 24) Clumsy 25) Unintentionally drop things V) Family History – Medical, social, psycho-emotional 1) Mother 2) Father 3) Siblings 4) Grandparents 5) Uncles 6) Aunts 7) Cousins 4 FOOD CHOICES Cross each type of food that you eat often (once a week or more): 1. Pre-made foods: a) canned food b) boxed cereals c) frozen dinners d) at restaurants 2. Red meat (beef, pork, lamb): a) commercially grown b) naturally raised 3. Chicken: a) commercially grown b) naturally raised 4. Turkey: a) commercially grown b) naturally raised 5. Fish a) canned tuna b) fresh fish c) frozen fish d) at restaurants 6. Fresh vegetables: a) commercially grown (store-bought) b) organically grown (store bought) c) organically grown (direct from farmers) d) from natural growers at a farmer’s market 7. Fresh fruit: a) commercially grown (store-bought) b) organically grown (store bought) c) organically grown (direct from farmers) d) from natural growers at a farmer’s market 8. Whole grains: a) commercially grown (store-bought) b) organic (store-bought) c) organic (direct from farmer) 9. Whole beans: a) commercially grown (store-bought) b) organic (store-bought) c) organic (direct from farmer) 10. Eggs/Butter: a) commercial eggs (store-bought) b) organic eggs c) commercial butter d) organic butter 11. Milk: a) commercial milk b) organic pasteurized milk c) organic goat’s milk d) good quality raw whole milk 12. Cheese: a) commercial cheese b) organic aged cheese (store-bought) 13. Other: a) commercial ketchup, mustard, spices b) commercial vinegar c) commercial olive oil 14. FOOD STRESSERS Please indicate how many times per week you consume the following foods: Stimulants Toxic Oils Commercial Dairy Highly Heated Foods Coffee (including decaf) Fried foods Cow’s Milk Bread (store-bought) Black tea, caffeine drinks Fast food Yogurt Cracker (store-bought) Soft drinks (colas, etc.) Potato or corn chips Ice cream Bagels (store-bought) Drinks with NaturaSweet Roasted nuts Cottage cheese Buns (store-bought) Alcohol (wine, beer, etc) Mayonnaise Sour cream Pasta (store-bought) Chocolate Margarine Cheese (commercial) Muffins (store-bought) Candy, pastries, sweets Peanut Butter (commercial) Cookies (store-bought) 5 Please tick the appropriate column () TOPIC Digestion Have you had……………….. Heartburn or reflux Bloating after meals Constipation Burping, Farting or wind Diarrhea or loose stools Nausea (feeling like vomiting) Stomach ulcers or Stomach pain Gall Bladder problems Lung Asthma or Emphysema Pneumonia or Bronchitis Wheeze after viral infection Wheeze after exercise Immune system Boils or pimples Cold sores Conjunctivitis Ear infection Genital infection Mouth ulcers Sinus infection Sore throat Thrush Tonsillitis Urinary infection Acne or pimples Brittle nails Dry eyes or mouth Dry skin Eczema or Dermatitis Early graying of hair Hair Loss Psoriasis Rashes Sore or cracked lips Tinea or ringworm Stretch marks White spots on nail Warts Skin, Hair & Nails TOPIC Urinary Heart Have you had……………….. Cystitis or Kidney infection Prolapse Stones Never In the past Recently Frequently Never In the past Recently Frequently Angina or Chest pain Cold hands & feet Fluid retention Heart Attack Heart Failure 6 Sleep Nervous system Heart Murmur High blood pressure Palpitations or Irregular heart rate Disrupted sleep Insomnia Snoring Unrefreshed sleep Agitation or Anxiety Irritability Migraine or other headache Poor night vision Gout Dizziness or vertigo Facial twitching Fidgeting or restless legs Fits or seizures Blurred vision Leg/foot or hand cramps Loss of balance Depression Memory loss Chronic pain Mood swings or irritability Muscle pain Muscle weakness / heaviness Pins & needles / Numbness Poor concentration Poor balance Tinnitus (ringing in the ears) Tremor of the hands Weakness of a limb Have you ever suffered from.........? Blood disorders Have you had blood clots? Blood Clot NO YES Year Anemia Low platelet count Iron deficiency Easy bruising Low white cell count Deep vein thrombosis Pulmonary embolus Have you ever suffered from..........? Osteoarthritis Rheumatoid arthritis Gout Lupus Ankylosing spondylitis Other Have you had cancer? Cancer Melanoma or other skin Breast Ovary or uterus Lung Lymphoma or leukemia 7 Stomach or Colon Other Have you ever had? Candida Chronic fatigue/fibromyalgia Helicobacter infection Glandular fever Leaky Gut Syndrome Mycoplasma Oral or genital herpes Ross river virus Shingles Do you have any of these? Hormone Do you have allergies? Allergy Any Liver problems? Liver Diabetes Thyroid problems NO YES List Medications Foods or herbs Hay fever or sinus trouble Nasal blockage Other NO YES Year Hepatitis or Jaundice Abnormal liver function tests Liver damage or fatty liver Have you ever had an accident? NO YES NO YES Car Plane Motorcycle Marine Bicycle Industrial Work Sporting Weight Overweight Anorexia Bulima Weight Loss Additional Information: 8