Health Questionnaire: A Self-Assessment

Transcription

1 1 Health Questionnaire: A Self-Assessment Phone: Fax: Main St Grandview, MO Please print clearly! Use a dark colored ink to ensure readability. Personal Information Date: Name: Gender: M F Age: Height: (ft.) Weight: (lbs.) Date of Birth: Address: City: State: Zip Code: Phone: Cell Phone: Alt. Phone: Occupation: Employer: Referred by: Chief Complaint(s) and reason why you are here: (Use separate sheet if more room is needed) Previous treatments for this complaint: Family Physician or health care professional: Do you currently smoke, drink coffee or drink alcohol? (how much and how often) Cigarettes Coffee Alcohol

2 2 History: List any major illnesses and approximate dates: Any history of: Antibiotics Allergies, eczema or psoriasis Food sensitivities Colicky or crying as a baby List any past surgeries and dates: Past accidents or injuries: List any major scars from surgery or injury: Dental History: Please give a history of cavities, crowns, or root canals: ** We apologize for the number of questions in the following pages. We know it is a lot! Please understand that your symptoms and the answers to these questions tell us an INCREDIBLE AMOUNT OF VALUABLE INFORMATION that is needed so that we can best serve you and guide you in better health. Vitals Information If you are not sure of your vital sign readings you may leave them blank. Eye Color: Blood Pressure: Right Left Pulse: Basal Temp.(F): ph (urine or saliva): How many bowel movements do you have per day? How often do you move your bowels per week? What does your current diet consist of? Be honest!

3 THYROID (GLANDULAR SYSTEM) 3 Do you get cold hands and/or feet? Do you feel cold often or have a hard time getting warm? Are you cold, but burning inside? Is it easy to put on weight and hard to lose it? Do you have an irregular heartbeat? Do you get headaches or migraines? Do you become irritable easily? Do you have low energy levels? Do you have, or have you ever had, a goiter? Have you been diagnosed with Hashimoto or Reidel disease? Has a family member? How much do you sweat? Low Medium Excessive PARATHYROID (GLANDULAR SYSTEM) Are your fingernails ridged, brittle or weak? Do you have varicose or spider veins? Do you, or have you had, hemorrhoids or prolapsed organs? Do you experience cramping in your muscles? Is your bladder strong or weak? Strong Weak Have you ever had a hernia? Have you ever had an aneurysm? Do you have osteoporosis and/or score low on your bone density tests? Do you have scoliosis? Do you suffer from symptoms of depression? Do you suffer from any other mental illness? Which?

4 PARATHYROID (GLANDULAR SYSTEM) C o ntinue d 4 Do your tests come back showing low Calcium levels? Do you have spine deterioration, herniated discs, or bone spurs? Do your legs get tired or cramp after you walk? Do you bruise easily? PANCREAS Do you get gas after you eat? Do you feel your foods just sitting in your stomach? Do you have Acid Reflux? Do you see any undigested foods in your stools? Are you thin and have a hard time putting on weight? Do your foods pass right through you (diarrhea)? Do you have moles on your body? (Adrenal & Pancreatic weakness) ADRENAL GLANDS (GLANDULAR SYSTEM) Are you overweight? Do you have M.S., Parkinson s or Palsy? Do you have anxiety attacks or feel overly anxious? Do you feel excessive shyness or inferior to others? Do you have tremors, nervous legs, etc.? Do you have High or Low Blood Pressure? Systolic Diastolic Do you have hypogylcemia (low blood sugar)? Do you have Diabetes (high blood sugar)? If yes: TYPE I or TYPE II Do you have tinnitis (ringing in the ears)? Do you have S.O.B. (shortness of breath) or is it hard to take a deep breath?

5 5 ADRENAL GLANDS (GLANDULAR SYSTEM) Continued Do you have heart arrhythmias? Do you have a hard time sleeping or insomnia? (pineal) Do you have Chronic Fatigue Syndrome? Have you ever been diagnosed with Addison s Disease or Congenital Adrenal Hyperplasia Do you have elevated blood cholesterol levels? Do you have arthritis, bursitis, or any inflammatory issues? Do you have any itis s (inflammatory conditions)? Which? (arthritis, bursitis, rheumatoid arthritis, colitis, enteritis, phlebitis, neuritis, etc.) Do you have low steroid or cortisol levels? Have you been diagnosed with Autism? Have you been diagnosed with ADD (attention deficit disorder) or ADHD (attention deficit hyperactivity disorder)? FEMALES ONLY Are your menstruation cycles irregular? (pituitary) Do you have excessive bleeding during menstruation? Do you have or have you had ovarian cysts? When? Do you have or have you had fibroids? When? Do you have or have you had endometriosis or A- typical cells? Which ones? Do you have or have you had fibrocystic breasts? When? Do you get sore breasts, especially during menstruation? Do you have a low or excessive sex drive? Have you had a hysterectomy? Date: Was it: Partial Complete

6 6 FEMALES ONLY Continued Did they take any other organs out at the same time? (i.e.: gallbladder) If yes, what other organs? Have you had a D & C? If yes, date: Have you had a miscarriage? When? Have you had difficulty conceiving children in the past or recently? Have you been on Birth Control Pills? For how long? : Are you currently pregnant? MALES ONLY Do you have prostatitis (frequent urination esp. at night)? If yes, how often do you urinate?: Do you have prostate cancer? What are your PSA counts?: date: Do you have testicular hypertrophy (enlargement)? Do you have a low or excessive sex drive? Do you have erection problems? Do you have premature ejaculation? Other: GASTRO- INTESTINAL TRACT Do you have gastritis or enteritis? Is your tongue coated (white, yellow, green or brown), especially in the morning? Do you have gastroparesis? Do you have a Hiatus Hernia? Do you have Colitis? Do you have Diverticulitis? Do you get or have Diarrhea?

7 7 GASTRO- INTESTINAL TRACT continued Do you get or have Constipation? Have you ever had stomach or intestinal ulcers? Do you or have you had any type of gastro- intestinal cancers? (stomach, colon, rectal, etc.) Explain: Do you have Crohn s Disease? Do you have gas problems? Other GI problems: LIVER / GALLBLADDER / BLOOD Do you have a problem digesting fats? Do fats or dairy foods cause bloating and/or pain in the stomach area? Are your stools white, or very light brown in color? Do you get pain in the middle of your back (especially after eating)? Do you get pain behind the right, lower rib area? Do you have liver or brown spots on your skin? (not freckles) Are you Jaundiced (yellowing of the skin) or eyes? Do you have any skin pigmentation changes? Are you or have you ever been anemic? Do you have, or have you ever had, hepatitis? If so: A, B, C. Do you consume alcohol regularly? How often?

8 8 HEART AND CIRCULATION Do you get chest pains or angina? Have you ever had a heart attack (Myocardial Infarction)? Have you ever had open- heart surgery? Do you have heart arrhythmia's? What kind? Do you ever feel pressure on your chest? Do you get prickly pains anywhere, especially in the heart area? Where? Do you have, or have you ever had High Blood Pressure? (kidneys) Do you have a Pacemaker or Stents? SKIN Do you get or have skin rashes? Do you get skin blemishes? Do you have Eczema or Dermatitis? Do you have Psoriasis? Do you itch anywhere? Where? Is your skin dry? Is your skin excessively oily? Do you get or have dandruff? Do you have any other skin problems? If so, what type? Do you have any tattoos? If so, where and how much of your body is covered? What is the approximate date of the most recent tattoo?

9 LYMPHATIC SYSTEM 9 Do you have hair loss or are you bald or going bald? Have you ever had Lymph Nodes removed? Where and how many? Do you have any gray hair? Do you have a hard time remembering things? Do you ever get colds or flu- like symptoms? Do you have fibromyalgia or scleroderma? Do you have sinus problems? Do you have or get sore throats? Do you have swollen lymph nodes? Do you have or have you had tumors? If so, where?: Type: Fatty Benign Malignant Do you have a low platelet count (blood)? Have you had appendicitis or an appendectomy? When? Do you get boils, pimples, cysts, etc.? Do you get regular exercise? How many times per week? What type of exercise? Have you ever had abscesses? Have you ever had toxemia? Do you have, or have you had, cellulitis? (not cellulite this is different!) Have you ever had gout? Do you get blurred vision? Do you have mucus in your eyes when you wake up in the morning?

10 LYMPHATIC SYSTEM continued 10 Do you snore? Do you have sleep apnea? Have you had your tonsils out? What age? KIDNEYS AND BLADDER Have you ever had a urinary tract infection (UTI s)? Have you ever had burning upon urination? Do you have problems holding your bladder? (parathyroid) Have you ever had kidney stones? Do you have bags under your eyes (esp. in the morning)? Is your urine flow restricted? Do you get cramping or pain on either side of your mid- to- lower back? Do you or did you ever have nephritis? Do you have lower back weakness? Do you have or have you had sciatica? Do you or did you ever have cystitis? LUNGS Do you get or have (or have had) bronchitis? Do you get or have (or have had) emphysema? Do you get or have (or have had) asthma? Do you get or have (or have had) C.O.P.D? Are you on inhalers or nebulizers? How often? What medication? Your oxygen saturation level is. Do you have pain when you breathe?

11 LUNGS continued 11 Do you have pain when you take a deep breath? (adrenals) Is it difficult to take a deep breath? Did you ever or do you have lung cancer? When? Do you or did you have a collapsed lung? When? Are you a smoker? How often? Packs per day OR cigarettes per day Have you ever had pneumonia? When and how often? Have you ever worked around toxic chemicals, in coal mines or around asbestos? Do you cough a lot? Do you remove any mucus when you cough? What color is the mucus? (clear, yellow, green, brown or black?) ENVIRONMENTAL AND OTHER TOXINS Have you been vaccinated? Have you had shots for traveling to foreign countries? Have you had Flu shots? Do you have mercury Amalgams? Have you been exposed to nuclear wastes or by- products, heavy metals or chemicals? Have you had radiation or chemotherapy? If so, how many treatments? Have you ever used any form of recreational drugs? (this information is confidential and used to help you obtain optimal health only!) If so, which drugs? Do you still use them?

12 13 MEDICATION CHEMICAL MEDICATIONS REASON FOR TAKING MEDICATION (List any chemical medications that you are presently taking) NATURAL SUPPLEMENTS (List any natural supplements you are taking) Mother: Father: Maternal Grandmother: Maternal Grandfather: Paternal Grandmother: Paternal Grandfather: Sibling: Sibling: Sibling: Sibling: GENETIC/FAMILY HISTORY (List the health issues if known of each family member)

13 Lawrence International, Inc., DBA Spirit of Health Release and Waiver of Liability 13 I, the undersigned, desire to participate in one or more consultation sessions with Vaughn Lawrence. Services Disclaimer. I understand and realize that Vaughn Lawrence is a lay natural health advisor, and T a medical doctor or licensed physician. Mr. Lawrence uses the traditional art of nutrition and wellness principles. I understand that these consultations are in no way medical treatments intended to diagnose, treat, prescribe, advise or cure any condition nor guarantee health related results. I understand that said consultations cannot determine specific disease conditions I may have and do not replaced the diagnostic services offered by a licensed physician. His services are purely informational and educational. Liability Release. In further consideration for my consultation(s) with Mr. Lawrence, I knowingly, voluntarily and expressively waive any current or future claim I may have against Mr. Lawrence or Lawrence International, Inc. DBA Spirit of Health, its employees, owners, contractors, instructors, directors, officers, volunteers or agents with respect to the ultimate outcome of my consultation or the use of any herbs or other supplements discussed during the course of my consultation(s). I also understand that any foods or supplements I choose to consume, or any natural therapies I choose to pursue are at my own discretion, of my own free will and at my own risk. I also understand that all 3 rd party information in the form of fliers, pamphlets and articles received are for informational and educational purposes only, and do not necessarily reflect the viewpoints of Mr. Lawrence. I further acknowledge and agree all waivers, releases and covenants made herein are binding on me, my family, estate, heirs or legal representatives. I further acknowledge that it is my responsibility to contact and consult with my primary care physician before starting or engaging in any natural health program, diets, supplements, or therapies. I will not discontinue, change or alter any medications or therapies that have been prescribed for me by a physician without first consulting the prescribing physician. I certify that I am here on this and on any subsequent visit or contact, whether by mail, telephone, or in person, solely on my own behalf and not as an agent or representative of any federal, state, county, or local government or private agency on a mission of investigation. Consent. I have carefully read, fully understand and agree to the contents of this contract. Print Name Date Signature