Naturopathic Health Services Phone: 248-625-0557 E-mail: DrCaruso@nhealths.com Doctor Nancy Caruso, ND Patient consultation questionnaire Patient Name __________________________________ Date of Birth __________________ Preferred Name ________________________________ Age:_______ Sex: _____ Patient Phone Number ___________________________ Cell Phone ____________________ Address__________________________________________________ Zip Code______________ E-mail (if you would like to receive monthly new letter) _______________________________ Please additionally list the name of the person who may have referred you for our service so we can be sure to thank them. (Name, address, zip, phone/fax, e-mail) Note to our patients: Holistic, naturopathic and preventive health care are only possible when the physician has a complete picture of the patient physically, mentally and emotionally. Therefore, please take the time to carefully and thoroughly complete this health history questionnaire. This will make our consultation time much more efficient and is essential for your specific health recommendation. Consider copying this for your own future records. Our initial examination involves an extensive review of this form along with any appropriate physical examination and recommendations. This form is for internal use and will not be released to any agency without your authorization. Problem List A. In your opinion what are your most important health concerns? 1. _________________________________ 5.________________________________ 2. _________________________________ 6. ________________________________ 3. _________________________________ 7. ________________________________ 4. _________________________________ 8. ________________________________ Other: ____________________________________________________________________ B. Which of the above problems are of most immediate concern to you? _______________ History of present illness A. Etiology How did these condition develop? Are there traumatic events (surgeries, drug reactions, life trauma ect.) that you can identify as having caused or clearly aggravated your health concern? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ B. Prior treatments and responses Please list all of the former treatment you have used, both conventional and alternative and the degree of effectiveness of each treatment. Please be specific about the benefits you received if any form each treatment. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ C. Prior doctor-patient relationship or health advisor relationship Please take a moment to reflect on your past relationship with physician and note how the relationship with future physicians could improve to optimize your health care. What do you need from a physician that you have not received? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Past medical history A. Your Health History Now Past Never Now Past Never __ __ __ Anemia __ __ __ Diabetes __ __ __ Arthritis __ __ __ Hypoglycemia __ __ __ Asthma __ __ __ Allergies __ __ __ Alcoholism __ __ __ Candida (Yeast) __ __ __ Bleeding __ __ __ Emphysema __ __ __ Cancer __ __ __ Eczema __ __ __ Colitis __ __ __ Drug/Alcohol use __ __ __ Heart Murmur __ __ __ Headache __ __ __ Blood Pressure __ __ __ Pneumonia __ __ __ Injury (serious) __ __ __ Rheumatism __ __ __ Kidney Disease __ __ __ Thyroid (Hyper or Hypo) __ __ __ Liver Disease __ __ __ Tuberculosis __ __ __ Overweight __ __ __ Venereal Disease __ __ __ Ulcers __ __ __ Depression __ __ __ Mental illness B. Hospitalization (list as best you can with dates) Type of illness or operations/procedures Date Summary of Findings ________________________________________ _____ ___________________ ________________________________________ _____ ___________________ ________________________________________ _____ ___________________ C. Imaging (X-ray, CT scan, Mammogram, Ultrasound, MRI, Angiogram, ect.) Date Summary of Findings _____________________________________ ____ __________________ _____________________________________ ____ __________________ _____________________________________ ____ __________________ E. Procedures (PAP, EKG, Stress test, Bronchoscope, Colonoscopy, ect.) Date Summary of Findings _____________________________________ ____ __________________ _____________________________________ ____ __________________ _____________________________________ ____ __________________ F. Labs(Blood, Urine analysis, PSA, thyroid) Date Summary of Findings _____________________________________ ____ __________________ _____________________________________ ____ __________________ _____________________________________ ____ __________________ G. Dental History Date of last dental exam and cleaning? _______________________ Did you ever have braces? _______________________ Did you ever have root cannel (if so when and how many)? ____________________ Do you have metal, mercury fillings (if so how many)? ________________________ H. Vaccinations: Please indicate the following vaccinations you have received: Polio___ Hep B ___ MMR (measles, mumps, rubella) ___ Tetanus ___ Chicken pox ___ Flu ____ (for how many years) Others _________________________________________________________ IV Family History: Please list ages and if deceased, what they died from at what age Please list any chronic health problems of your living parents and siblings A. Ancestral Medical History Mother side Fathers Side Grandfather________________________ Grandfather ______________________ Grandmother ______________________ Grandmother _____________________ Mother ___________________________ Father __________________________ Sister _________________________________________ Sister _________________________________________ Sister _________________________________________ Brother ________________________________________ Brother ________________________________________ Brother ________________________________________ B. Has any Blood Relative had any of the following? Yes No Don’t Know Yes No Don’t Know __ __ ___ Anemia __ __ ___ Hay Fever __ __ ___ Arthritis __ __ ___ Heart attack __ __ ___ Asthma __ __ ___ High blood pressure __ __ ___ Bleeding __ __ ___ Seizure/Epilepsy __ __ ___ Cancer __ __ ___ Sickle Cell Anemia __ __ ___ Diabetes __ __ ___ Stroke __ __ ___ Eczema __ __ ___ Thyroid (hyper/hypo) __ __ ___ Glaucoma __ __ ___ Tuberculosis __ __ ___ Gout __ __ ___ Venereal disease (specify) __ __ ___ Depression __ __ ___ Mental illness V. Medication A. Please list all medications that you have taken and are currently taking: Currently taking Taken in the past __________________________ ____________________________ __________________________ ____________________________ __________________________ ____________________________ __________________________ ____________________________ __________________________ ____________________________ B. Please list all supplements that you have taken and are currently taking Currently taking Taken in the past __________________________ ____________________________ __________________________ ____________________________ __________________________ ____________________________ __________________________ ____________________________ __________________________ ____________________________ VI. Allergic History A. Medication/drug allergies: ___________________________________ B. List any known allergies (food, air born, ect.) Presently: ______________ _________________ ________________ ______________ _________________ ________________ Past: _______________ _________________ ________________ _______________ _________________ ________________ C. What allergen is most bothersome to you? ______________ D. What prior types of allergy testing have you had? Intradermal _ Scratch _ Blood IgG Food _ Blood IgE Inhalant/Food _ Electroacupuncture _ Kinesiology _ Food Intolerance _ Cytotoxic _ None _ VII. Health Habits A. Alcohol How often do you drink: Wine________ Beer ________ Other __________ B. Tobacco: Do you use tobacco or have you in the past? Yes/No If yes how many years _____ How many pack a day (if used cigarettes _____ Have you stopped? Yes/No If you have stopped, how long has it been _____ C. Chemical exposure: Have you ever been exposed to toxic chemical, solvent or other possible toxins? Yes/No If yes please explain _______________________________________________ E. Exercise: Do you exercise? Yes/No If yes: How often ___________ What do you do for exercise _________________ F. Relaxation: Do you make time for rest, relaxation or meditation during the day? Yes/No If yes: How often ____________ How do you relax? ________________________ G. Hobbies: What are your interests or hobbies? _____________________________________________________ H. Diet: How many meals do you general eat each day? ____________ Who cooks the food you eat? ______________________________________________________ List the primary foods included in your diet? __________________________________________ List the food you exclude from your diet? ____________________________________________ What foods that you crave regardless of their nutritional value? ___________________________ What foods give you adverse reaction? ______________________________________________ I. Water Do you get thirsty? Yes/No How much water do you consume a day? ______ What kind of water are you consuming (tap, distilled, filtered, spring, ect.)? _________ J. Sleep Do you have trouble falling asleep? Yes/No If yes what keeps you awake? _______________________________________________ Do you sleep strait through the night? Yes/No Do you wake felling refreshed? Yes/No VIII. Female Health Section A. Menstrual cycle: Date of First menstruation? ______________ Did you have a normal puberty? _____ Date of last Menstrual Period ____________ Length of flow is typically ____ day Length of cycle is typically ____ days (Between 1st day of menses and 1st day of next menses) Do you experience cramps (describe)? ___________________________________________ Do you experience emotional/mood swings (describe)? ______________________________ B. PAP History Date of last PAP _________________ Any irregular PAP _______________________ C. Pregnancy Have you had in the past or do you currently have problem with infertility? ______________ #of pregnancies ___ # of living children __ # of miscarriages __ # of abortions__ Complications with pregnancy? Yes/No If yes please explain? ______________________ Have you ever used birth control pills? Yes/No If yes how long? _____________________ Did you have any side effects with the birth control? _____________________________ Have you ever used an I.U.D.? Yes/No How long? _________ What kind? ________ Did you have any side effects with the I.U.D.? __________________________________ Are you currently sexually active? ____________ Form of birth control if any? ________ X. Review of Systems Instructions: A = Mild B = Moderate C = Severe If it does not apply to you leave it blank! Sympathetic dominance Parasympathetic Dominance A B C A B C 1. _ _ _ Acid foods upset stomach 1. _ _ _ Joint stiffness after arising 2. _ _ _ Feel chilled often 2. _ _ _ Muscle leg toe cramps at night 3. _ _ _ Lump in throat 3. _ _ _ “Butterfly” stomach, cramps 4. _ _ _ Dry mouth, eyes, nose 4. _ _ _ Eyes or nose watery 5. _ _ _ Pulse speeds after meals 5. _ _ _ Eyes blink often 6. _ _ _ “Keyed up”, unable to feel calm 6. _ _ _ Eyelids swollen or puffy 7. _ _ _ Cuts heal slowly 7. _ _ _ Indigestion soon after meals 8. _ _ _ Gag easily 8. _ _ _ Always seem hungry; “lightheaded” often 9. _ _ _ Unable to relax, startles easily 9. _ _ _ Food digests rapidly 10. _ _ _ Extremities cold and/or clammy 10. _ _ _ Vomit frequently 11. _ _ _ Strong light irritates 11. _ _ _ Frequently hoarse 12. _ _ _ Urine amount reduced 12. _ _ _ Irregular breathing 13. _ _ _ Heart pounds after retiring 13. _ _ _ Pulse slow or feels “irregular” 14. _ _ _ Nervous stomach 14. _ _ _ Slow gag reflex 15. _ _ _ Appetite reduced 15. _ _ _ Difficulty swallowing 16. _ _ _ Cold sweats often 16. _ _ _ Alternating constipation and diarrhea 17. _ _ _ Body temperature rise easily 17. _ _ _ “Slow starter” 18. _ _ _ Skin sensitive to touch 18. _ _ _ Not easily chilled 19. _ _ _ Staring, blinks little 19. _ _ _ Perspire easily 20. _ _ _ Frequently have a sour stomach 20. _ _ _ Poor circulation or sensitive to cold 21. _ _ _ Subject to colds, asthma,bronchitis Sugar Handling Cardiovascular A B C A B C 1. _ _ _ Eat when nervous 1. _ _ _ Hand and feet go to sleep easily,numbness 2. _ _ _ Excessive appetite 2. _ _ _ Sigh frequently, “air hunger” 3. _ _ _ Hungry between meals 3. _ _ _ Aware of “breathing heavily” 4. _ _ _ Irritable before meals 4. _ _ _ Discomfort at high altitude 5. _ _ _ Get “shaky” if hungry 5. _ _ _ Opens windows in closed room 6. _ _ _ Feeling fatigued, eating relieves 6. _ _ _ Susceptible to colds and fevers 7. _ _ _ “Lightheaded” if meals missed 7. _ _ _ Afternoon “yawner” or delayed 8. _ _ _ Get “drowsy” often 8. _ _ _ Afternoon headaches 9. _ _ _ Swollen ankles worse at night 9. _ _ _ Upset feeling from excessive eating 10. _ _ _ Muscle cramps, worse during of sweets exercise;“charley horses” 11. _ _ _ Shortness of breath on exertion 10._ _ _ Awaken after a few hours sleep, 12. _ _ _ Dull pain in chest or radiating hard to get back to sleep into left arm, worse on exertion 11._ _ _ Crave candy or coffee in afternoons 13. _ _ _ Bruise easily, “Black/Blue” spots on arms or legs 12._ _ _ Moods of depression, “blues”, 14. _ _ _ Tendency to anemia or melancholy 15. _ _ _ Frequently have “noses in head” 16. _ _ _ “Ringing in ears” or noises in 13._ _ _ Abnormal craving for sweets or snacks head 17. _ _ _ Tension under the breast bone, Liver/Biliary or feeling of tightness A B C in the chest gets worse with exertion 1. _ _ _ Dizziness 2. _ _ _ Dry skin 3. _ _ _ Burning feet 4. _ _ _ Blurred vision 5. _ _ _ Itching skin and feet Digestion 6. _ _ _ Excessive falling hair A B C 7. _ _ _ Frequent skin rashes 1. _ _ _ Loss of taste for meat 8. _ _ _ Bitter or metallic taste in mouth 2. _ _ _ Lower bowel gas several hours in the morning after eating 9. _ _ _ Bowel movements painful or difficult 3. _ _ _ Burning stomach sensation, 10. _ _ _ Feelings of worry, dread, or insecurity eating relieves 11. _ _ _ Feeling queasy; headache over eyes 4. _ _ _ Coated tongue 12. _ _ _ Greasy foods upset 5. _ _ _ Pass large amounts of foul smelling gas 13. _ _ _ Stools light colored 6. _ _ _ Indigestion ½ - 1 hr after eating; may be up to 3-4hrs 14. _ _ _ Skin peels on foot soles 7. _ _ _ Mucus colitis or irritable bowel 15. _ _ _ Pain between shoulder blades 8. _ _ _ Gas shortly after eating 16. _ _ _ Using laxatives 9. _ _ _ Stomach “bloating” after eating 17. _ _ _ Stools alternate from soft to watery 18. _ _ _ History of gallbladder attack or gall stones 19. _ _ _ Sneezing attacks 20. _ _ _ Dreaming, nightmares type bad dreams 21. _ _ _ Bad breath (halitosis) 22. _ _ _ Milk products cause distress 23. _ _ _ Sensitive to hot weather 24. _ _ _ Burning or itching anus 25. _ _ _ Crave sweets Hyperpituitary Hyperthyroid A B C A B C 1. _ _ _ Failing memory 1. _ _ _ Insomnia 2. _ _ _ Low blood pressure 2. _ _ _ Nervousness 3. _ _ _ Increased sex drive 3. _ _ _ Can’t gain weight 4. _ _ _ Headaches, “splitting or rendering” type 4. _ _ _ Intolerance to heat 5. _ _ _ Decreased sugar tolerance 5. _ _ _ Highly emotional 6. _ _ _ Flush easily 7. _ _ _ Night sweats 8. _ _ _ Skin is thin and moist 9. _ _ _ Inward trembling 10. _ _ _ Heart palpitates 11. _ _ _ Increased appetite without weight gain 12. _ _ _ Pulse races when resting 13. _ _ _ Eyelids and face twitch 14. _ _ _ Irritable and restless 15. _ _ _ Can’t work under pressure Hypopituitary A B C Hypothyroid 1. _ _ _ Abnormal thirst A B C 2. _ _ _ Bloating of the abdomen 1. _ _ _ Noticeable weight gain 3. _ _ _ Weight gain around hips or waist 2. _ _ _ Decrease in appetite 4. _ _ _ Sex drive reduced or lacking 3. _ _ _ Easily fatigued 5. _ _ _ Tendency toward ulcers and or colitis 4. _ _ _ Ringing in ears 6. _ _ _ Increased sugar tolerance 5. _ _ _ Sleepy during day 7. _ _ _ (Female) Menstrual disorder 6. _ _ _ Sensitive to cold 8. _ _ _ (Young Girls) Lack of menstrual function 7. _ _ _ Dry or scaly skin 8. _ _ _ Constipation Hyperadrenal 9. _ _ _ Mental sluggishness A B C 10. _ _ _ Hair coarse, falls out 1. _ _ _ Dizziness 11. _ _ _ Headaches upon arising wear 2. _ _ _ Headaches off during day 3. _ _ _ Hot flashes 12. _ _ _ Slow pulse, below 65 beat 4. _ _ _ Increased blood pressure per minute 5. _ _ _ (Female) Hair growth on face or body 13. _ _ _ Frequent urination 6. _ _ _ Sugar in urine (not diabetes) 14. _ _ _ Impaired hearing 7. _ _ _ (Female) Masculine tendencies 15. _ _ _ Reduced initiative Hypoadrenal Foundational Issues A B C A B C 1. _ _ _ Weakness and/or dizziness 1. _ _ _ Apprehension 2. _ _ _ Chronic fatigue 2. _ _ _ Irritability 3. _ _ _ Low blood pressure 3. _ _ _ Morbid fears 4. _ _ _ Nails weak and/or ridged 4. _ _ _ Never seems to get well 5. _ _ _ Tendency toward hives 5. _ _ _ Forgetfulness 6. _ _ _ Arthritic tendencies 6. _ _ _ Indigestion 7. _ _ _ Perspiration increases 7. _ _ _ Poor appetite 8. _ _ _ Bowel disorders 8. _ _ _ Craving for sweets 9. _ _ _ Poor circulation 9. _ _ _ Muscular soreness 10. _ _ _ Swollen ankles 10. _ _ _ Depression; Felling of dread 11. _ _ _ Crave salt 11. _ _ _ Noise sensitivity 12. _ _ _ Brown spots or bronzing of skin 12. _ _ _ Acoustic hallucinations 13. _ _ _ Allergies – tendency to asthma 13. _ _ _ Tendency toward hives 14. _ _ _ Muscular and nervous exhaustion 14. _ _ _ Nervousness 15. _ _ _ Respiratory disorders 15. _ _ _ Headache 16. _ _ _ Insomnia Female Only 17. _ _ _ Anxiety A B C 18. _ _ _ Anorexia 1. _ _ _ Very easily fatigued 19. _ _ _ Inability to concentrate; confusion 2. _ _ _ Premenstrual tension 20. _ _ _ Frequent stuffy nose; sinus infections 3. _ _ _ Painful menses 21. _ _ _ Allergy to some foods 4. _ _ _ Depressed feelings before menstruation 22. _ _ _ Loose joints 5. _ _ _ Excessive and prolonged menstruation 6. _ _ _ Painful breasts 7. _ _ _ Menstruate to frequently 8. _ _ _ Vaginal discharge 9. _ _ _ Hysterectomy/ovaries removed 10. _ _ _ Menopausal hot flashes 11. _ _ _ Menses scanty or missed 12. _ _ _ Acne, worse at menses 13. _ _ _ Long standing depression Male only A B C 1. _ _ _ Prostate trouble 2. _ _ _ Urination difficult or dribbling 3. _ _ _ Frequent night time urination 4. _ _ _ Depression 5. _ _ _ Pain on inside of legs or heels 6. _ _ _ Feeling of incomplete bowel evacuation 7. _ _ _ Lack of energy 8. _ _ _ Migrating aches and pains 9. _ _ _ Too easily tired 10. _ _ _ Avoids activity 11. _ _ _ Diminished sex drive Thank you for taking the time to fill this out. The information provided will help me to serve you better as we work together toward health! If you have any additional questions or comments please feel free to ask, e-mail, or write.