Patient Profile
Today's Date:
Name:Age:Date of Birth:Sex:
Address:City:State:Zip:
Telephone: (Home)(Work)S.S.#:
Occupation:Full or Part Time:
Employer:
Address:City:State:Zip:
Education:Referred by:
Are you: _ Married _ Separated _ Divorced _ Single _ Cohabitating
Live with: _ Spouse _ Partner _ Parents _ Relatives _ Friends _ Pets _ Alone
Next of kin (or emergency name):Relationship:
Address:City:State:Zip:
Telephone: (Home)(Work)
A NOTE TO OUR PATIENTS: Naturopathic, hollistic, and preventive health care require the physician to have a complete picture of the patient physically, mentally and emotionally. Please take the time to complete this health history questionnaire carefully and thoroughly.
CURRENT HEALTH CONDITION
When, where and from whom did you last receive medical or health care?
What are your most important health concerns?
1.5.
2.6.
3.7.
4.8.
Which of the above problems are of most immediate concern?
Do you have any contagious diseases at this time: _ Yes _ No
If yes, what?
CURRENT MEDICATIONS
Do you take or use:
_ Laxatives_ Pain relievers_ Antacids_ Cortisone
_ Tranquilizers_ Thyroid medication_ Sleeping pills_ Antibiotics
_ Appetite supressants_ Nasal decongestants_ Birth control pills_ Hormones
Please list any prescription or over-the-counter medications, vitamins or other supplements you are taking and dosages:
1.5.
2.6.
3.7.
4.8.
FAMILY HISTORY
FatherMotherBrothersSistersChildren
Ages (if living)
Health
Age at death
Cause of death
Check those applicable:
Anemia_____
Arthritis_____
Asthma/Hayfever/Hives_____
Cancer_____
Diabetes_____
Glaucoma_____
Gout_____
Heart Disease_____
High Blood Pressure_____
Kidney Disease_____
Mental Illness_____
Seizures/Epilepsy_____
Stroke_____
Thyroid problems_____
FOR THE FOLLOWING, PLEASE MARK:
YES=a condition you now have NEVER=a condition you never had PAST=a condition you have had before
YES NEVER PASTYES NEVER PAST
Head
Headaches/migraines___Head injury___
Double vision___Jaw/TMJ problems___
Dizziness___Fainting spells___
Eyes
Glasses or contacts___Impaired vision___
Spots in eyes___Cataracts___
Blurriness___Eye pain/strain___
Color blindness___Tearing or dryness___
Sensitivity to light___Glaucoma___
Ears
Discharge from ears___Pain in ears___
Hearing problems___Ringing in ears___
Sensitivity to noise___Many ear infections___
Nose and Sinuses
Frequent colds___Nose bleeds___
Stuffiness___Hayfever___
Sinus problems___Loss of smell___
Mouth and Throat
Frequent sore throat___Copious saliva___
Teeth grinding___Mouth ulcers___
Bleeding gums___Hoarseness___
Speech difficulties___Loss of voice___
Neck
Lumps___Swollen glands___
Goiter___Pain or stiffness___
Cardiovascular
Heart disease___Angina___
High blood pressure___Low blood pressure___
Blood clots___Fainting___
Phlebitis___Palpitations___
Rheumatic fever___Chest pain___
Swelling in ankles___Heart murmurs___
YES NEVER PASTYES NEVER PAST
Respiratory
Cough___Sputum production___
Spitting up blood___Wheezing___
Asthma___Bronchitis___
Pneumonia___Pleurisy___
Emphysema___Difficulty breathing___
Pain on breathing___Shortness of breath___
Tuberculosis___ " " lying down___
Night sweats___ " " at night ___
Gastrointestinal
Trouble swallowing___Heartburn___
Bad breath___Bad taste in mouth___
Change in thirst___Change in appetite___
Nausea___Vomiting___
Vomiting blood___Constipation___
Blood in stool___Diarrhea___
Pain or cramps___Gall bladder disease___
Belching___Ulcers___
Passing gas___Hemorrhoids___
Eating disorder___Distress from eating fats ___
Black stools___Jaundice___
Liver disease___Bad body odor___
Bowel movements: How oftenIs this a change? _ Yes _ No
Male reproduction
Hernias___Testicular mass___
Testicular pain___Prostate disease___
Discharge or sores___Herpes___
Syphillis___Chlamydia___
Gonorrhea___Condyloma___
Premature ejaculation___Impotence___
Vasectomy__Painful erections___
Sexual orientation: _ Heterosexual _ Bisexual _ HomosexualSexually active_ _ _
Female reproduction/breasts
Age of first mensesCycles regular___
Length of cycleBleeding between cycles ___
Duration of mensesPain during intercourse___
Painful menses___Clotting___
PMS___Birth control___
If yes, please list your symptoms:Type
Number of pregnancies
Number of live births
Endometriosis___Number of miscarriages
Ovarian cysts ___Number of abortions
Difficulty conceiving___Menopausal symptoms___
Cervical dysplasia___Abnormal PAP___
Sexual difficulties___Vaginal discharge___
Pelvic pain___Chlamydia___
Gonorrhea___Condyloma___
Herpes___Syphilis___
Do you do breast exams__Breast pain/tenderness___
Breast lumps___Nipple discharge___
Sexual orientation: _ Heterosexual _ Bisexual _ HomosexualSexually active_ _ _
Urinary
Pain on urination___Increased frequency___
Frequency at night___Inability to hold urine___
Many urinary infections ___Problems starting urine___
Blood in urine ___Kidney stones___
YES NEVER PASTYES NEVER PAST
Musculoskeletal
Joint pain or stiffness___Arthritis___
Broken bones___Weakness___
Muscle spasms or cramps___Back pain___
Blood/peripheral vascular
Easy bleeding/bruising___Anemia___
Deep leg pain___Cold hands/feet___
Varicose veins___Thrombophlebitis___
Fluid retention___Bleeding from unusual places___
Emotional
Treated for emotional problems___Anxiety/nervousness___
Mood swings___Depression___
Considered/attempted suicide___Tension___
Excessive worry___Panic attacks___
Neurologic
Seizures/epilepsy___Paralysis___
Muscle weakness___Numbness or tingling___
Loss of memory___Easily stressed___
Vertigo or dizziness___Loss of balance___
Endocrine
Hypothyroid___Heat/cold intolerance___
Hypoglycemia___Diabetes___
Excessive thirst___Excessive hunger___
Fatigue___Seasonal depression___
Unexplained weight loss/gain___Change in sexual desire___
Immune
Vaccinations___Reactions to vaccinations___
Chronic fatigue syndrome___Chronic infections___
Chronically swollen glands___Slow wound healing___
Skin
Rashes___Eczema/hives___
Acne/boils___Itching___
Color changes___Hair loss___
Lumps___Warts___
Habits
Use alcoholic beverages___Ever treated for alcoholism___
If yes, list types and amounts:
Use recreational drugs___Ever treated for drug dependence ___
If yes, list types and amounts:
Smoke tobacco products___Chew tobacco products___
If yes, list types and amounts:
Drink coffee___
If yes, amount:
Drink black tea___ Drink cola___
Eat out often___Go on diets often___
Eat excessive sugar___Eat excessive salt___
GENERAL INFORMATION
Weight:lbs.Weight 1 year ago:lbs.
Maximum weight:lbs.When:
Height:ft. in.
When is your energy the best during the day?Worst?
CHILDHOOD ILLNESSES
_ Rubella (German 3-day measles)_ Measles (2 week)_ Mumps_ Chickenpox
_ Whooping cough_ Rheumatic fever_ Polio_ Scarlet fever
_ Roseola_ Asthma_ Others
IMMUNIZATIONS
_ Pertussis_ Tetanus_ Polio_ Diptheria
_ Measles/Mumps/Rubella_ Hepatitis_ Others
X-RAYS AND SPECIAL STUDIES
_ Electrocardiogram (EKG)_ Electroencephalogram (EEG)_ Intravenous Pyelogram (IVP)
What x-rays, CAT scans, or other studies have you had?
HOSPITALIZATION AND SURGERY
What hospitalizations or surgeries have you had?
ALLERGIES
Are you hypersensitive or allergic to:
Any drugs:
Any foods:
Any chemicals or environmental toxins:
What happens to you when you have an "allergy attack?"
What prior types of allergy testing have you had?
_ Intradermal_ Scratch_ Blood IgG food_ Blood IgE inhalant/food_ Electroacupuncture
_ Kinesiology _ Cytotoxic_ Food Intolerance _ None
TYPICAL FOOD INTAKE
Breakfast:
Lunch:
Dinner:
Snacks:
LIFE STYLE
Main interests and hobbies:
Do you exercise? _ Yes _ No
If yes, what kind?
Do you have a religious or spiritual practice? _ Yes _ No
If yes, what kind?
Do you eat 3 meals a day? _ Yes _ No
If no, how many?
Do you average 6-8 hours sleep? _ Yes _ No
If no, how many?
Do you sleep well? _ Yes _ No
If no, what is the problem?
Do you awaken rested? _ Yes _ No
If no, what is the problem?
Do you enjoy your work? _ Yes _ No
If no, why not?
Do you spend time outside? _ Yes _ No
If yes, how much and in what form?
Do you watch television? _ Yes _ No
If yes, how much?
Do you read? _ Yes _ No
If yes, what and how much?
Do you take vacations? _ Yes _ No
If yes, how long and what kind?
Do you have a supportive relationship? _ Yes _ No
If no, what's wrong with it?
Do you have a history of abuse or trauma? _ Yes _ No
If yes, please describe:
CURRENT ILLNESS OR CONDITION
How does your condition affect you?
What do you think is happening?
Why?
What do you feel needs to happen for you to get better?
What do you enjoy most in life?
How much change are you willing to make at this time for improving your health?
1
Dr. Bronner Handwerger N.D.
8950 Villa La Jolla Dr. #A107 Tel:858-254-5433 Fax:866-463-9349