Select the appropriate section, print out and fill out or check what is
appropriate and
fax the form(s) to 480-237-5436 or bring them with you.
General health information (circle and fill
out)
Name
Address
Phone
#
Referred
by
Current
MD
/Person
to contact in emergency
Health
issues (list all)
Medications
(current--circle and past)
Nutritional
Supplements/herbs
Hospitalized
Frequent
childhood illness/Respiratory illnesses-do you get sick often?
Breathing issues?
Coffee/Smoking/Drugs/
Alcohol
Dizziness/Fainting/Headaches/Foggy
head
Allergies/Skin
conditions/Asthma
Hepatitis/Gall
bladder issues/HIV/Venereal
Diseases
Blood
pressure--high/low/Cholesterol/Blood sugar
Varicose
veins, Circulation issues, Heart palpitations, Pain or Tightness in the chest
Body
pains/Lymph nodes enlarged/ Bloody discharge/Easy bruising
Itching/
Numbness/ Stiffness/ Spasm/ Shaking
Libido
(sex drive)/Energy level during day
Insomnia,
Excessive sleeping, Heavy Dreaming/Nightmares
Urinary
issues/Bowel movement-regular/irregular/constipation/diarrhea/loose
Appetite/
Cravings/Thirst/Sweating
Gas/
Bloated/ Acid regurgitation/Nausea
Worry
a lot, fearful, irritable/impatient, angry outbursts, sad
Dislike
heat, cold, damp, dry
Anything else you want to
mention?
Women's Health:
How old when started first menses (and stopped if applies)?
Are
you pregnant?
Are
you on a birth control pill /which one/how long/any side effects?
Number
of births/miscarriages/abortions/other surgeries?
Past
pregnancy (list if any problems)?
Menstr.
cycle (early, late, regular, none)?
Any
vaginal discharges or spotting?
Ovulation
time (pain or other symptoms)?
PMS
(bloated, cramps, edema, moody)?
Length
of bleeding (days)?
Amount
of blood (heavy, scanty)?
Color
of blood (pale, fresh, dark)?
Quality
(watery, normal, sticky)?
Clots/Cramps/Feeling
Cold/Hot flushing/Low energy level?
Last
OBGYN check up? Anything abnormal?
Breasts
(swollen, fibrocystic, painful)?
Cysts/Fibroids/Endometriosis/Abnormal
pap smear?
Venereal
diseases/vaginal discharge--white/yellow/other?
Family
history of breast, uterine, etc. cancer?
Hormone
blood results: estrogen, progesterone, thyroid, FSH/LH etc.?
Taking
any hormones?
Checked
for osteoporosis-results?
Menopausal
symptoms--flushing, sweating, palpitations, dry vagina, insomnia, irritable,
urinary issues?
History
of smoking, blood clots, epilepsy, hypertension or heart attack?
History
of sexual abuse (optional)?
History
of depression?
Pain Management
When did your pain start and where is it?
Is it injury/illness related/work injury? Explain.
How intense is the pain now? (on scale from 1-10, 1 being very little
pain, 10 being the most pain).
Does it fluctuate during the day--describe?
What medical tests have you had for this condition(s)?
Have you had it treated (MD, chiropractor, etc.)?
History of your injuries/accidents/falls in your life span?
Are (were) you on any medication/herbs/supplements for this pain?
Is the pain static or does it travel?
Is it sharp, dull, achy?
Is it worse with movement/stillness, day/night, warm/cold,
damp/dry/wind, emotional outburst—circle appropriate?
How much do you sit, stand, walk per day? Do you carry heavy objects?
Do you feel the pain is in the joints, muscles, bones, organs?
Do you do any sport activities?
Do you have a history of abnormal blood clotting or bleeding?
Do you have a history of heart condition, stroke, depression, chronic
slow bowels, menstrual issues (clotting, cramps)?
Energy level/sleep quality?
Menopause
(fill in and circle if applicable)
Hot flashes (use scale 1,2,3,4,5,6,7,8,9,10) and indicate when worse—morning,
afternoon, evening; worse when doing or feeling…………….
Fatigue/
Dry throat/mouth/no desire to drink
Depression/anxiety/irritability/nervousness/fright
Suffocating sensations/mood swings
Over-thinking/unable to think & concentrate/forgetfulness
Insomnia—cannot fall asleep, wake up often, restless sleep
Palpitations/hypertension/hot palms
Frequent urination/feeling of heaviness
Breast distention/cold nipples
Low back pain/hypochondriac pain/chest pain/hip pain
Dry Vagina or discharge/painful intercourse/low libido
Heartburn/acid reflux
Headaches/light-headedness/dry eyes
Constipation/diarrhea/flatulence/bloating
Tongue and mouth sores
Menses—how often, amount, clots
Cold extremities/edema
Dizziness/vertigo
Pregnancy
Name of your OB/GYN MD?
Person to contact in case of emergency?
List all your pregnancy related health issues?
List all the tests done to monitor your pregnancy?
Do you have insurance and which hospital (where) do you intend to give birth?
Can we contact your doctor for more information if needed? If yes, please, give
a contact information.
How long have you been pregnant?
How many children do you have (list their health issues if any)?
How many abortions?
How many miscarriages?
Were there any complications with previous pregnancies and/or the current
pregnancy?
Where you hospitalized for your pregnancy –currently or in the past?
Are you on any medication or herbal supplements?
Do you suffer from seizures?
Do you have high blood pressure, morning sickness, varicose veins, feel tired,
hemorrhoids, low back pain, bowel problems, urinary issues?
Do you drink coffee/tea/alcohol or smoke?
Are you under lots of stress or suffer from anxiety, depression?
Do you get all the support you need/want?
Fertility
--women
Do you have any children?
How long have
you been trying to get pregnant?
Have you tried
any method of assisted reproduction? If yes, list the MD and the procedure(s).
Any miscarriages/ abortions/D&C/ectopic
pregnancy/pelvic surgery (if
yes, which part of pregnancy?)
Describe your history of birth
control method.
Have you had any sexually transmitted
diseases/viral
infections/allergies/autoimmune diseases/cancer/candida overgrowth?
Hormone level test (FSH, LH,
prolactin, estrogen, progesterone, thyroid)?
Any long term exposure to
chemicals (and your husband?)
Are you stressed out? (on scale
1-10—1 being the least)?
Do you have anxiety/depression or
other similar conditions?
Have you been diagnosed with
fibroids, ovarian cysts, endometriosis, polycystic ovaries, pathological vaginal
discharge, hypothyroidism, tilted uterus, etc.?
Ob/Gyn exams-any pathologies (last
10 years)?
Describe you menstrual cycle
(regularity, length, amount)? Menarche (1st period):
Do you keep BBT or keep tract of
your cycle; do you test
yourself for ovulation (how)?
Sleep quality?
Do you get cold/hot easily?
Do you take
medication/herbs/vitamins?
Has your partner been evaluated
for sperm quality (list all the workup done)?
Do you have diabetes/high blood pressure or other
health conditions?
Fertility--Men
List current health issues
List chronic health issues
History of infections (plus list if you have had yeast, veneral diseases, HIV,
Hepatitis, Mumps, etc.)
Do you have high blood pressure, diabetes, high cholesterol, or heart condition?
Have you had your sperm quality and quantity tested? Were you diagnosed with
varicocele or sperm antibodies?
Have you had your hormones level checked (testosterone, LH, FSH, DHEA, cortisol)?
Do you drink alcohol, smoke, take recreational drugs (how often?)
Do you eat sugars or take stimulants-coffee, coke, tea-how much?
Have you taken any pharmaceutical drugs for a prolonged period of time? Have you
used any steroids for muscle building?
Have you had any injury to your reproductive organs?
Have you worked with chemicals--consider both work and hobbies?
Do you suffer from depression or anxiety, and are very stressed out?
Do you have any of the following:
-inability to have an erection; loss of libido (sexual drive); inability to
maintain an erection; premature or
none or difficult ejaculation; pain during intercourse
Are you in front of a computer/TV often? Do you do air travel often?
Mark if you have any of the following:
-lumbago, weak legs, low libido,
copious clear urine, feel often tired
-thirsty, bitter taste, cramps in
the perineum, clouded urine, fullness in the epigastrium
-allergies (specify)
Detox
Are you/were you in contact with toxic materials (work,
pastime, hobby, etc.)
Do you live in a house that is over 25 years old?
Have you had a recent remodeling done in your house? Did
your health change?
Do you use dry cleaners often?
Do you commute long distances?
Do you sleep close to electronic equipment?
Do you play on public
lawns frequently?
Do you have any neurological problems?
Do you get sick easily?
Check the following if you have them
Skin rashes
Digestive problems
Fatigue and exhaustion
Swollen glands
Depression/anxiety
Irritability
Difficulty concentrating
Indecision
Numbness/tingling in extremities
Memory loss
Irregular heart beat Headaches
Low grade fever
Joint pains
Muscular disorders Chest pain/pain
under arms
Drowsiness
Dizziness
Candida/yeast infections
Diarrhea/Constipation
Loss of appetite
Autoimmune disorders
Allergies
Weight loss/weight gain
Foul breath
Excessive sweating
All
the intake forms are subject to copyright law.
