Download patient questionaire

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:
_______________________________
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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
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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....
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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
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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)
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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
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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
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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:
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