LaserBodyBalanceCenter
HEALTH HISTORY QUESTIONNAIRE
IF YOU NEED ANY ASSISTANCE COMPLETING THIS FORM, PLEASE ASK THE FRONT DESK
PATIENT INFORMATION:Today’s Date:______Date of Birth______
Name: ______
Address______City______Prov_____ Zip______
Home Phone: ______Work Phone ______Cell /Pager: ______
MaleFemaleEmail address ______
Marital Status:MarriedSingleDivorcedSeparatedOther ______
Mother’s Name, if minor______Father’s Name, if minor______
Name of Individual to contact in case of emergency: ______Phone: ______
Number of Children: ____ Ages: ____
Your Occupation: ______
Referred to this office by: Friend or Patient – Name? ______Other______
Briefly describe the reason for your visit and what you hope to accomplish: ______
______
______.
What type of care are you looking for? Temporary Relief Maximum Recovery
ARE YOU PREGNANT?NOYES
Please List Possible Foods that Cause Symptoms ______
______.
Please List What Animals Cause Symptoms. ______
______.
ARE YOU ALLERGIC TO ANY MEDICATIONS? NO YES / PLEASE LIST MEDICATIONS AND REACTIONS:
MEDICATIONREACTION
______/ ______
______/ ______
______/ ______
more?… PLEASE LIST ADDITIONAL MEDICATION ALLERGIES ON THE BACK OF THIS PAGE.
ARE YOU CURRENTLY TAKING ANY MEDICATIONS? NO YES / PLEASE LIST: 1.) ______
2.) ______3.) ______4.) ______
5.) ______6.) ______7.) ______
more?… PLEASE LIST ADDITIONAL MEDICATIONS, YOU ARE CURRENTLY TAKING, ON BACK OF THIS PAGE.
THESE PROBLEMS ARE: RAPIDLY IMPROVING SLOWLY IMPROVING GRADUALLY WORSENING
FLUCTUATES BUT GETTING BETTER REMAINS THE SAME RAPIDLY WORSENING
SYMPTOMS ARE WORSE IN THE Morning Afternoon Evening
SYMPTOMS/COMPLAINTS: COME & GO ARE CONSTANT
AGE WHEN SYMPTOMS STARTED
Infant (Age 0-3) Adolescent (Age 13-18) Adult (Age 26-40)
Child (Age 4-12) Adult (Age 19-25) Adult (Age 41+)
NAME ANDCITY/STATE OF DOCTORS/HEALTH CAREPROVIDERS PREVIOUSLY SEEN FOR PRESENT CONDITION(S): ______
______
IMPORTANT INFORMATION FOR ALLERGY PATIENTS
● An Allergy is NOT a disease. It is nothing more than your body reacting inappropriately to what should be a
harmless substance, consequently activating the body’s natural defense mechanism in the form of symptoms.
● A symptom is an attempt by your body to tell you that something is wrong.
● We will be treating the root cause of your inflammation / allergy.
● We do not use medications in this program.
● Our procedures are safe, painless and effective for people of all ages.
PLEASE MARK WHICH SYMPTOMS or CONDITIONS APPLY:
Updated 1/27/2012
SYMPTOMS ARE WORSE: YES / NO
Outdoors, and better indoors /
At nighttime /
In the bedroom or when in bed /
During windy weather /
During wet or damp weather /
When the weather changes /
During known pollen seasons /
In certain rooms or buildings /
When exposed to tobacco smoke /
Yard Work, cut grass, leaves, or hay /
Sweeping or dusting /
In Air conditioned rooms /
FREQUENCY & SEVERITY OF SYMPTOMS:
YES / NO Constant, chronic with little change /
Present Most of the time / Present part of the time / Present rarely / Interferes with normal life / Slight interference with normal life / Considerable effect on normal life / Prevents most normal activities /
SYMPTOMS ARE BETTER:
YES / NO
/ After shower or bath
/ In an air conditioned room
/ Indoors
/ During or after physical activity
/ After taking medication
GENERAL:
YES / NO
/ Recent weight gain
/ Recent Weight loss
/ Fatigue
/ Fever
/ Loss of appetite
/ Chills
/ Cancer of Any Kind
NEUROLOGICAL:
Right Now/In the Past/Never
/ / Lightheaded/Dizzy
/ / Memory loss
/ / Headaches
/ / Migraines
/ / Numbness
/ / Weakness (Muscle)
/ / Stroke
/ / Tingling/Numbness
NASAL SYMPTOMS:
Right Now/In the Past/Never
Itching / / Sneezing / / Runny Nose – Clear discharge / / Runny Nose – Cloudy discharge / /
Worse during pollen season / /
Post nasal drip / /
Nose Bleeds / /
EYE SYMPTOMS:
Right Now/In the Past/Never
Itching / / Excessive watering / / Redness / / Swelling / / Worse during pollen season / / Worse with animal exposure / / Worse with smoke or chemical
exposure / /
Blurred vision / / Double vision / / Glaucoma / /
CHEST & RESPRITORY SYMPTOMS:
Right Now/In the Past/Never
Dry Coughing / / Wet Coughing / / Tightness Chest Pain / / Asthma/Wheezing with Exercise / / Asthma/Wheezing around Animals / / Asthma/Wheezing during Pollen
Season / / Asthma or Wheezing around Smoke / / Shortness of Breath / / Frequent Bronchitis / / Recurring Pneumonia / / Emphysema / / COPD / / Coughing Up Blood / / Tuberculosis / /
CARDIOVASCULAR:
Right Now/In the Past/Never
Heart Attack / / Swelling of Ankles / /
High Blood Pressure / /
Low Blood Pressure / /
Pain Down left Arm / / Profuse Sweating / /
High Cholesterol / /
THROAT & MOUTH SYMPTOMS:
Right Now/In the Past/Never
/ / Itching of the Throat and Mouth
/ / Frequent Sore Throats
/ / Frequent Laryngitis
/ / Hoarseness
/ / Frequent Tonsillitis
/ / Mouth Sores
/ / Swelling of Tongue or Mouth
/ / Dental problems
EAR SYMPTOMS:
Right Now/In the Past/Never
/ / Itching
/ / Hearing Loss
/ / Blocking, Fullness, Popping
/ / Frequent Ear Infections
/ / Ear Tubes Inserted
/ / Ringing in Ears
/ / Ear pain
CHRONIC GASTROINTESTINAL SYMPTOMS
Right Now/In the Past/Never
/ / Nausea & Vomiting
/ / Diarrhea
/ / Gas, Heartburn
/ / Cramps or Bloating
/ / Abdominal Pain
/ / Gall Bladder Problems
/ / Liver Problems
/ / Pain over Stomach
/ / Ulcers
/ / Colitis
/ / Hiatal Hernia
/ / Blood in Stool
GENITOURINARY:
Right Now/In the Past/Never
/ / Painful Urination
/ / Blood in Urine
/ / Frequent Urination
/ / Kidney Infection
/ / Kidney Stones
/ / Incontinence
SKIN SYMPTOMSRight Now/In the Past/Never
With allergy shot / / Itching / / Hives / / Rashes / / Sores / / Eczema / / Swelling / / Rashes in the bends of
knees & elbows / /
Worse during pollen season / / Worse with animal exposure / / Skin symptoms are chronic / /
Bruise Easily / / Discoloration / / Changes in Moles / / Scars / / Skin symptoms are rare / /
BONE & JOINT SYMPTOMS:
Right Now/In the Past/Never
/ / Arthritis
/ / Rheumatoid Arthritis
/ / Broken Bones
/ / Osteoporosis
/ / Gout
/ / Scoliosis
/ / Spinal Trauma
/ / Bone & Joint
/ / Redness or Swelling of Joints
/ / Joint Stiffness, Limited Motion
/ / Muscle Pain
/ / Muscle Weakness
Updated 1/27/2012
WHICH SYMPTOMS ARE THE MOST BOTHERSOME? ______
PLEASE EXPLAIN WHAT YOU HAVE DONE TO TRY TO CORRECT THE SYMPTOMS
______
HAVE ALL OF THESE TREATMENTS FAILED TO CORRECT YOUR PROBLEM? YES NO
HOW HAS THIS PROBLEM AFFECTED YOUR DAILY ACTIVITIES?
PLEASE CICLE YOUR LEVEL OF DISCOMFORT ON THE SCALE BELOW.
NO DISCOMFORT 1 2 3 4 5 6 7 8 9 10 WORST
I the undersigned confirm that the above information is correct to the best of my knowledge:
______DATE:
Physician/Staff Signature
Updated 1/27/2012