First O.V. Health Assessment Questionaire

FIRST O.V. HEALTH ASSESSMENT QUESTIONAIRE

Date______Referred by______PrimaryPhysician______

Mr. / Mrs. / Ms.______

LastFirstMiddle

Sex______Age______Birthdate ____/____/____ Marital status M____ S____ D____ W____

Occupation______Height ______Weight ______

Primary reasons you came to us for evaluation______

______

Primary Physician______

Other health care providers you are now seeing, and their specialties

1. ______

2. ______

3. ______

When did you last feel really well?______

Have you recently had a physical exam?______What diagnosis(es) were you given?______

Date of most recent procedure. Circle any tests that were abnormal.

Chest x-ray ______TB test______Colonoscopy ______

Blood & urine test ______Cholesterol______PSA______

Mammography ______PAP test______Bone density ______

Cardiac stress test______EKG______X-rays______MRI______CAT scan______Other______

Past Medical History:

How was your health as a child? (circle one): excellent good fair poor

Hypertension______Yes____ No____ Emotional or psych problems _ _ _ _ Yes____No____

Stroke ______Yes____No____ Lyme disease ______Yes____No____

Heart disease or PACEMAKER ______Yes____No____ Recurrent bladder infections_ _ _ _ _ Yes____No____

Diabetes______Yes___ No ____ Thyroid disease______Yes___ No ____

Cancer ______Yes____ No ____ Seizures ______Yes____ No___

Peptic ulcer disease______Yes____No____Tuberculosis or lung disease _ _ _ _ Yes____No____

Colitis or intestinal diseases ______Yes____No____ Hepatitis (A) (B) (C) ______Yes____ No____

Kidney disease______Yes____No____ HIV+______Yes____No____

Liver or gallbladder disease______Yes____No____ Anticoagulants (blood thinners) _ _ _Yes____ No____

Asthma______Yes____No____ Skin cancer______Yes____ No____

Eczema, Hay fever ______Yes____ No____ Cataracts ______Yes____ No____

Hives or Psoriasis ______Yes____ No____Glaucoma______Yes____ No____

Immune compromised condition _ _ _ _Yes____ No____ Bleeding disorder ______Yes___ No____ Recurrent Sinusitis ______Yes____ No____ Fever blisters or cold sores _ _ _ _ Yes___ No____

Blood type: A_____ B_____ O_____ AB_____

Mercury amalgam fillings _____ Root canals_____ Frequent tooth infections______

Significant weight gain or loss _ _ _ _ Yes____ No_____ Explain:______

Family Medical History:

Cancer_____: Breast___ Ovarian___ Other Cancer______

Heart Disease___ Stroke____ Asthma____ Allergies____ Alcoholism____ Diabetes ___

Other (Specify))______

Major illnesses / surgery / trauma______Year______

______Year______

Are you considering any elective surgical or medical procedures in the near future?_____

Allergies:

Medicines:Penicillin____ Aspirin____ Codeine_____ Xylocaine ______Other______

Environmental:Pollen ______Dust______Mold______Latex______Nickel______Chemicals______

Foods: Eggs_____ Soy _____ Lactose _____ Gluten _____

Other______

Women only:

Number of children_____ Age of youngest______Number of miscarriages / C-sections______

Age at onset of menstruation______Age at onset of menopause______

Sleep:How many hours of sleep do you get each night?______Do you wake rested?______

Stress: Rate your stress level from 1-10______Do you have a good support network / team?_____

What are the major stress factors in you life now?______

How many hours of relaxation (not including sleep) do you give yourself during a work week?_____

Does your home environment have a supportive effect on your health?______

Prescription medicines taken within last 2 months, and reasons for taking them:

______

Supplements currently taking; include vitamins, herbals, homeopathy, and OTC drugs:

______

Have you ever been on: Steroids _____ Birth control pills______Acid blockers_____ AIDS Meds______Antidepressants_____ Antidiabetic_____ Aspirin_____ NSAIDS_____ Heart meds_____ Hormones_____ Laxatives_____ Lithium_____ Prostate meds_____ Radiation_____ Recreational drugs_____ Specify:_____ Relaxants / Sleeping pills_____ Thyroid_____ Ulcer medications_____ Cancer chemotherapy____ Immune suppressing medication______Blood pressure medication_____

Have you been exposed to frequent doses of antibiotics at any time during your life?______

For what problem?______

Environmental Exposures:

Tick bite______Bulls-eye rash______Joint swelling______Headaches______

Tingling numbness______Bell’s Palsy ______

Diagnosed with Lyme disease______Date(s)______Treatment date(s)______

Basement floods______Mold exposure______

Chemicals at work______Paint____ lawn chemicals ______Play or work on or near golf courses______Antiperspirants or antacids with aluminum______House or workplace under construction______

Do you smoke? ______years ______Packs per Day

If you’ve quit, when did you quit______Passive smoking?______

Exercise:Do not exercise often_____Exercise (What type and frequency?):______

Is your lifestyle or occupation: Strenuous______Moderate ______Light ______Sedentary______

Diet: Frequently on a diet ____ Difficulty loosing weight______or gaining weight_____

Recent weight gain or loss _____Poor appetite ____Excess appetite____Cravings____

What are your favorite foods?______

PLEASE CHECK ALL SYMPTOMS THAT APPLY

IMMUNE

HIV+____ Mononucleosis_____ CFIDS (Chronic fatigue immune deficiency syndrome____

Fibromyalgia_____Feel worse after exercising___Frequent infections or colds___

Slow to recover from cold or flu____ Bad reactions to chemicals, pesticides, or perfume___

Cold sores or fever blisters____Muggy days and moldy places provoke symptoms____

Nose runs or drips____ Nose bleeds____ Loss of smell or taste____

Throat infections or chronic sore throat____ Chronic swollen lymph glands____

Chills____ Sweat easily____Fevers____ Poor sleep____ Sudden energy drop at____(Time) Heavy sleep____ Fatigue____ Night sweats___ Low blood sugar____

Feeling cold when others don’t______Inability to sweat______

HEAD, EYES, EARS, NOSE, AND THROAT

Headaches/ Migraines ____ (Where and when)______

Concussion____ Sinus problem ____ Eye strain or pain____ Cataracts____ Glasses____

Color blindness ____ Poor or blurry vision____ Spots in eyes____ Night blindness____

Poor hearing____ Ringing in the ears ____ Earaches ___ Grinding teeth____ Jaw clicks____

Tooth problems ____ Inflamed or bleeding gums____ Recurrent sore throats ( __ times per month) Dry throator mouth ____ Copius saliva____ Sores on lips or tongue____

Nosebleeds____ Other head or neck problems______

SKIN AND HAIR

Rashes____ Ulcerations ____ Itching ____ Dandruff ____ Eczema____ Hives____

Allergies____ Pimples or boils____ Change in hair / skin texture____

Hair falls out or grows slowly____ Excessive sweating____ Recurrent sores____

Brittle or fungal nails____ Bleed or bruise easily ____ Scars or keloids____

Poor wound healing____ Dry skin or cracking fingertips ____ Bumpy skin on back of arms____

CARDIOVASCULAR

High BP____ Low BP____ Chest pain ____ Irregular heartbeat____ Dizzyness____

Anemia____ Fainting____ Cold hands / feet____ Swelling in hands / feet____

Blood clots or phlebitis____ Chest tightness ____ Shortness of breath____

Varicosed veins____ Tingling of hands or ankles____ Restless legs in evening____

Calf muscles cramp while walking____

RESPIRATORY

Cough____ Phlegm (What color) ____ Coughing blood____ Asthma____ Pneumonia____ Bronchitis____ Other lung problems____ Frequent colds____

GASTROINTESTINAL

Nausea____ Vomiting____ Constipation____ Diarrhea____Bloody or black stools

Laxitive use ( __ times / wk.) ____ Pain or cramps____ Gas or belching____ Bad breath____

Hemorrhoids____ Irritable bowel____ Heartburn____ Sour taste in mouth____

Bloating after eating____ Intolerance to greasy foods____

GENITOURINARY

Cystitis___ Wake up to urinate____ Blood in urine____ Impotence ____ Kidney stones____

Pain on urination____ Frequent urination____ Urgency to urinate____ Other GU problems____

PREGNANCY AND GYNECOLOGY

# of pregnancies____ # of births____ # Miscarriages____ Premature births____

Birth control pills____ Breast lumps____ Vaginal sores____ Irregular Menses____

Heavy menstrual bleeding____ Bleeding between periods____ Passing clots____

Missed periods____ PMS symptoms (Swelling, breast tenderness, mood swings)____

Menopause Symptoms____

NEUROPHYSIOLOGICAL

Seizure____ Stroke____ Depression____ Treated for emotional problems____

Muscle weakness____Parasthesias (Tingling sensations)____Loss of memory____

Poor coordination ____ Insomnia ____ Nervousness _____ Anxiety____Social Anxiety___

Localized weakness____Poor coordination____ Tremors____ Vertigo (Room spinning)____

MUSCULOSKELETAL

Neck pain____ Back pain____ Herneated disc_____ Joint pains (Where______)

Muscle pains____ Carpel tunnel syndrome____ Gout____ Multiple tender areas____

Restless legs at night____ Muscle aches and pains with normal activity____ Muscle cramps____

Please indicate painful areas on body charts.

Please circle pain level for each area and name it below.

______0 1 2 3 4 5 6 7 8 9 10

Patient’s Signature______