CENTER FOR NATURAL HEALTH HEALTH INFORMATION FORM
NAME___________________________________ HOME ADDRESS_________________________ CITY, STATE, ZIP_________________________ HOME TELEPHONE_______________________ CELL PHONE_____________________________ DATE OF FIRST APPOINTMENT____________ DATE OF BIRTH______________AGE________ WEIGHT_____________HEIGHT_____________ OCCUPATION____________________________ WORK TELEPHONE_______________________ PERSONAL MEDICAL DOCTOR____________ ADDRESS________________________________ E-Mail Address_____________________________ Blood Type__________________
1)________________________________________ 2)________________________________________ 3)________________________________________ 4)________________________________________ 5)________________________________________
_________________________________________
Are you interested in being on our mailing list for programs & workshops?
HEALTH HISTORY LIST ALL SURGERIES YOU HAVE HAD: _______________________________________ ______________________________________________________________________________ LIST ALL CHILDHOOD ILLNESSES: ___________________________________________ LIST ALL HOSPITALIZATIONS:________________________________________________ ______________________________________________________________________________ LIST ALL ACCIDENTS AND INJURIES__________________________________________ ______________________________________________________________________________ LIST ALL AREAS OF PAIN (experienced in the past four months): ___________________ ______________________________________________________________________________ LIST ALL DIAGNOSED OR SUSPECTED ILLNESSES, DISEASES AND HEALTH PROBLEMS___________________________________________________________________ ______________________________________________________________________________ LIST ALL KNOWN ALLERGIES________________________________________________
ALLERGIES TO MEDICATIONS_________________________________________ LIST METHOD OF BIRTH CONTROL (IF ANY):__________________________________ LIST ALL PRESCRIPTION MEDICATIONS TAKEN WITHIN THE PAST 12 MONTHS ______________________________________________________________________________ LIST ALL NON-PRESCRIPTION MEDICATIONS TAKEN WITHIN THE PAST 12 MONTHS (ASPIRIN, HORMONES, LAXATIVES, ANTACIDS, TRANQUILIZERS, etc.) ______________________________________________________________________________ ______________________________________________________________________________ LIST ALL VITAMINS, MINERALS, ENZYME, GLANDULAR OR HERB SUPPLE-MENTS YOU HAVE RECENTLY TAKEN OR ARE NOW TAKING__________________ ______________________________________________________________________________ ______________________________________________________________________________ BRIEFLY DESCRIBE ANY DIETARY PROGRAM YOU ARE FOLLOWING: _________ ______________________________________________________________________________ BRIEFLY DESCRIBE ANY EXERCISE PROGRAM YOU ARE FOLLOWING ON A REGULAR BASIS: _____________________________________________________________ BRIEFLY IDENTIFY STRESS FACTORS , MAJOR OR MINOR, WHICH YOU ARE AWARE OF:
SOCIAL:____________________________________ FAMILY: _______________________________ SCHOOL OR WORK:_________________________ ENVIRONMENTAL: _____________________ OTHER: ________________________________ Briefly note diseases and surgeries experienced by your immediate family: Age Spouse:_______________________________________________________________________ Parents: Father:__________________________________________________________ Mother:__________________________________________________________ Sisters:________________________________________________________________________ Brothers:______________________________________________________________________ Children:______________________________________________________________________ WHEN WAS YOUR MOST RECENT EXAM BY A MEDICAL DOCTOR?_____________ DESCRIBE DONE:________________________________________________ NOTE ANY RELIGIOUS OR PERSONAL BELIEFS RELEVANT TO HEALTH, ILLNESS OR TREATMENT METHODS (IF ANY):__________________________ LIFESTYLE: Cigarettes________pack/day caffeine_______drinks/day alcohol______drinks/day Recreational drugs_____________ Meditation/Relaxation______________________ Sugar________________/day Water_____________________/day ****************** SYMPTOMS SURVEY I If you have had any of these symptoms within the past year, check the box next to them: ο Coughed up blood or vomited blood. ο Noticed black or bloody stool, brown black or bloody urine. Noticed a yellowing in the whites of your eyes. o Have had a nagging cough, hoarseness, or a sore throat that did not heal within 10 days. Have had a breast lump, or unexplained lump or cyst anywhere in the body. Have had unexplained thickening anywhere in the body. Have experienced marked unexplained weight loss, shortness of breath or any dramatic change in normal body functioning. Have had a crushing pain in the center of your chest, that may have been accompanied by pain radiating down the left arm, severe nausea, clammy skin, difficulty breathing or an irregular heartbeat. Have had a cut sore or lesion that hasn’t healed or an obvious enlargement or change in warts and moles. Have experienced unexplained rapid or irregular heartbeats. Have experienced unexplained dizziness, blurring or distorted vision, fainting spells or blackouts or prolonged fatigue or exhaustion. Have experienced a blow to the head that caused unconsciousness. Have had abdominal pain that lasts for 12 hours or more and is very intense for several hours. Have had an obvious blockage of the intestinal tract. Have swallowed any dangerous, poisonous chemicals, drugs or highly toxic substances. Have been in an accident and suffered lacerations, serious abrasions, broken bones, possible whiplash or other injuries known or suspected. Have had a great tightness in the chest or great difficulty swallowing. Have had an oral temperature over 102 degrees farenheit for more than Have a hernia. Have taken prescription drug, Zelnorm. Oversensitivity to drugs, herbs or supplements.
∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗
SYMPTOMS SURVEY II If you are presently experiencing any of these symptoms, check the box next to them. This survey provides health history information and considerations for your health and healing program. General Notes general fatigue or weariness wear glasses or contacts shortness of breath with normal activities. wear sunglasses trembling eyesight worsening numbness seeing double dizziness see halos or lights lack of endurance eye pains or itching balance ο watering eyes or dry eyes memory ο redness in eyes hearing difficulties weight ο earaches appetite ο noises in ears excessive appetite other notes:____________ difficulty sleeping fever or chills fainting Respiratory System motion sickness other notes:___________________________ congested nose Number of bowel movements per day _____ sinus problems Number of hours sleep per night _________ running nose Quality of sleep per night________________ sneezing spells Number of times you awaken to urinate____ head colds How do you feel when you awaken? _______ chest colds Do you live in peaceful surroundings?______ difficulty breathing deeply nosebleeds sore throat difficulty swallowing Rashes, flaking, itching, burning skin hoarse voice lesions, cysts, calluses, lumps wheezing or gasping cold/warm hands or feet excessive mucous /phlegm swelling edema. swollen feet or ankles frequent coughing excessive perspiration ο other notes:___________ Urinary System cracked or chapped lips frequent urination problems ο involuntary escape of urine burning or discharge cracking or discolored nails weak urine stream other notes____________________________ difficulty starting urine constant urge to urinate Other symptoms____________________________ bedwetting other notes:___________ Cardiovascular System Endocrine rapid or skipped heartbeats swollen glands varicose swelling in armpits or groin excessive thirst, hunger, urination slow or fast metabolism frequently colder than others blood sugar imbalances frequently warmer than others night sweats other notes:__________________ hot flashes other notes:_________________ Neuromusculoskeletal System ο headaches: frequency____severity_____ Digestive System neck or shoulder pain recurring indigestion, heartburn back or hip pain flatulence or gas arm or hand pain nausea, vomiting leg or foot pain cramping in abdomen cramping bloated abdomen weakness in arms or legs constipation diarrhea stiffness grey or whitish stools other notes______________________ pain or itching in rectum excessive appetite /lack of appetite Dental System other notes:________________ problems sore or bleeding gums Women Only halitosis or bad breath bleeding between periods tension or pain before periods vaginal discharge jaw pain or tension rash, irritation /pain in genital area other notes:_____________________ pain on intercourse swelling or soreness in breasts burning or discharge on urination age menstruation began:_______ lumps or swelling on testicles age at menopause:____________ pain in prostrate or testicles frequency of periods__________
ο impotence > amount of bleeding during periods: other notes:_____________________ regular little excessive sporadic ____number of pregnancies ___cesareans ____miscarriages ___abortions ____premature births ____number of births nervousness or anxiety nail biting difficulty making decisions ο loss of memory annoyed easily lack of concentration problems at work depressed/moody sought psychiatric help considered suicide angered easily frightening dreams /thoughts ο difficulty relaxing worry a lot change of sexual energy sexual difficulties hopeless outlook feeling of desperation frequent crying shy or sensitive Assessing Your Exposure Risk~
Your mother took prescription diethylstilbestrol (DES), the first synthetic estrogen ever marketed, or another synthetic hormone when she was pregnant with you?
You consume a diet low in animal fats ? You consume nonorganic dairy products. You have town chlorinated water. You use hair coloring or permanent hair dye You dry clean some clothes. You eat nonorganic, commercially grown foods. You eat canned foods and drinks. You microwave food in plastic containers or cover foods with plastic cling wrap. You use pesticides on your lawn and garden or bombs in your home. You use sun screens and insect repellent on your skin. Your pets wear flea collars. You use regular washing detergent. You use air fresheners in your home or car or deodorizers in your bathroom. You use solvents or chemicals in your work, home or hobbies or have been exposed to them in the past. You use synthetic sweeteners such as nutri-sweet, aspartame, etc. o You drink diet soda, regular soda or sport drinks Served in the military in Vietnam. Had a blood transfusion before 1992. You have been exposed to chemicals other than those listed above. Explain:____________________________________________________ ___________________________________________________________
ISMP List of High-Alert Medications in Community/Ambulatory Healthcare igh-alert medications are drugs that bear a heightened risk ofThis may include strategies like providing mandatory patient education; H causing significant patient harm when they are used in error. improving access to information about these drugs; using auxiliaryAlthough mistakes may or may not be more common with t
La organización y utilización de medios tecnológicos en el Instituto Proyectos Vicente Ruiz Antón (profesor de Música) La realidad de la evolución de la sociedad ha hecho necesaria una revisión de los medios utilizados en el proceso enseñanza-aprendizaje. En un sistema educativo basado en la formación en competencias, en el que la clase magistral ha dado paso a otro tipo de relac