PATIENT HEALTH APPRAISAL
Alternative Health Care of Western Massachusetts
Gary S. Lasneski, M.S., D.C.
59 Interstate Dr.
West Springfield, MA 01089
Phone (413) 455 2168
PLEASE FOLLOW THESE INSTRUCTIONS CAREFULLY
IMPORTANT: The information requested in this form is of vital importance in determining the care and correction of your health problem. Please write neatly and be as accurate as possible.
Read each question carefully and score only those statements which pertain to you.
If a question does not apply to you, leave it blank. If you are not sure and have a doubt about a question, or wish to clarify the answer, describe in the space available.
Name ______Age ______Today’s Date ______
Address ______City ______State ______Zip ______
Phone (Home) ______Date of Birth ______Sex: M F Marital Status: S M D W #Children______
Email Address: ______
Occupation ______Employer ______Phone (Work) ______
Emergency Contact ______Phone Number ______
Referred By ______
YOUR MAJOR REASON FOR SEEING THE DOCTOR: ______
______
Have you ever been treated for this problem? * NO * YES
If yes, by * Physician * Doctor of Chiropractic * Physical Therapist * Osteopath * Other
What did they do/ recommend? ______
When did your symptoms appear? ______Is this condition getting progressively worse? * Yes * No * Unknown *
Is it constant or does it come and go?______
Does it interfere with * Work * Sleep * Daily Routine * Recreation
Activities which are difficult to perform * Sitting * Walking * Bending * Lying down * Other______
______
CONDITIONS Check conditions you have or have had in the past.
* Aids * Diabetes * Liver Disease * Rheumatic Fever
* Alcoholism * Emphysema * Measles * Scarlet fever
* Anemia * Epilepsy * Migraine headaches * Stroke
* Anorexia * Fractures * Miscarriage * Suicide attempt
* Appendicitis * Glaucoma * Mononucleosis * Thyroid problems
* Arthritis * Goiter * Multiple Sclerosis * Tonsillitis
* Asthma * Gonorrhea * Mumps * Tuberculosis
* Bleeding disorders * Gout * Osteoporosis * Tumors, growths
* Breast lump * Heart disease * Pacemaker * Typhoid fever
* Bronchitis * Hepatitis * Pneumonia * Ulcers
* Bulimia * Hernia * Polio * Vaginal infections
* Cancer * Herpes * Prostate Problem * Venereal disease
* Cataracts * High Cholesterol * Prosthesis * Whooping Cough
* Chemical dependency * HIV Positive * Psychiatric care * Other
* Chicken pox * Kidney disease * Rheumatoid arthritis
______
MEDICATIONS List any medications you are currently taking VITAMINS/HERBS/MINERALS
______
______
Allergies______
Pharmacy Name ______Phone ______
OPERATIONS AND PROCEDURES
Date Date Date
Vaccinations Tubes in Ears Sinus
Tonsillectomy Appendectomy Hernia
Gall Bladder Female Organs Thyroid
Back operation Rectal Surgery Stomach
Other Other Other
* I have never had any operations / surgeries.
Your doctor is interested in helping you in the following areas of your health naturally and without side effects:
SCORE THE SEVERITY OF SYMPTOMS IN EACH SQUARE BELOW FROM 1 TO 5
1. Very Mild or Occasional
2. Mild
3. Moderate EXAMPLE: * Do you have headaches?
4. Severe ______
5. Very Severe
GENERAL DESCRIBE
001 * Are you overweight? ______
002 * Are you underweight? ______
003 * Do you rarely exercise? ______
004 * Do you smoke? ______
005 * Do you drink alcoholic beverages daily? ______
006 * Do you use recreational drugs? ______
007 * Do you drink less than 6 glasses of water daily? ______
008 * Sexual problems? ______
009 * Are you often dizzy? ______
010 * Do you experience spells of rapid heart beat? ______
011 * Are you aware of your heart skipping beats? ______
012 * Blood pressure problems? ______
013 * Circulatory problems? ______
014 * Do you have cold hands or feet? ______
015 * Do you have varicose veins? ______
016 * Do you have excessive thirst? ______
017 * Do you frequently feel hot? ______
018 * Are you unusually tired most of the time? ______
019 * Are you unusually jumpy or nervous? ______
020 * Do you have epilepsy? ______
021 * Do you suffer from motion sickness? ______
022 * Eye condition? ______
023 * Other ______
024 * Other ______
025 * Other ______
026 * Other ______
SKIN
027 * Teenage acne? ______
028 * Middle age acne? ______
029 * General unhealthy skin? ______
030 * Oily, dry, or itchy skin? ______
031 * Eczema – Psoriasis or cracking skin? ______
032 * Cysts, warts, moles, liver spots, fungal growths? ______
033 * Rashes, vesicles? ______
034 * Herpes or Shingles? ______
035 * Are you troubled with boils? ______
036 * Do you get sore that are slow to heal? ______
037 * Do you bruise easily? ______
038 * Other ______
IMMUNE
039 * Food allergies? ______
040 * Sensitivity to chemicals? ______
041 * Hay fever? ______
042 * Asthma? ______
043 * Emphysema? ______
044 * Frequent colds or flu? ______
045 * Frequent sore throats? ______
046 * Are your glands often swollen? ______
047 * Frequent laryngitis? ______
048 * Frequent cough? ______
049 * Do you have a chronic chest condition? ______
050 * Do you have post nasal drip? ______
051 * Frequent sinusitis? ______
052 * Is your nose frequently stuffy? ______
053 * Do you spit up phlegm? ______
054 * Frequent earaches or discharges? ______
055 * Hair or nail problems? ______
056 * Weakness or exhaustion? ______
057 * Eating relieves fatigue? ______
058 * Feel shaky when hungry? ______
059 * Poor concentration? ______
060 * Crave sweets or stimulants? ______
061 * Loss of memory? ______
062 * Confusion? ______
063 * Other? ______
DIGESTION/ ENDOCRINE
064 * Do you have stomach ulcers? ______
065 * Do you have liver or gall bladder disease? ______
066 * Are you diabetic? ______
067 * Do you get lightheaded when standing quickly? ______
068 * Do you have excessive hunger? ______
069 * Do you eat when nervous? ______
070 * Do you have black, tarry or bloody stools? ______
071 * Constipation? ______
072 * Do you use laxatives? ______
073 * Diarrhea or colitis? ______
074 * Indigestion, gas or bloat? (When) ______
075 * Heartburn? ______
076 * Hemorrhoids, fissures, polyps? ______
077 * Have you even had intestinal worms, itchy nose or rectum? ______
078 * Gout? ______
079 * Are you frequently nauseated? ______
080 * Have you been diagnosed with a thyroid condition? ______
081 * Are you on any hormone replacement? ______
082 * Other ______
NEUROMUSCULOSKELETAL
083 * Do you have rheumatoid arthritis? ______
084 * Does any part of the body experience numbness, tingling? ______
085 * Back problems? ______
086 * Spinal curvature? ______
087 * Do you suffer from muscle spasms? ______
088 * Are you muscles frequently sore? ______
089 * Do you have muscle weakness? ______
090 * Are your joints stiff in the morning? ______
091 * Do you suffer from painful feet? ______
092 * Do you have plantar warts? ______
093 * Do you have heel spurs? ______
094 * Are you troubled with corns? ______
095 * Sciatica? ______
096 * Headaches, sinus, or migraine? ______
097 * Sports injuries? ______
098 * Jaw problems? ______
099 * Tremors or neurological disease? ______
100 * Other ______
MEN
101 * Prostrate, dribbling after urination? ______
102 * Impotency, decreased sexual desire? ______
103 * Other ______
WOMEN
104 * Are you pregnant? ______
105 * Do you take birth control pills? ______
106 * Do you have pre-menstrual depression? ______
107 * Is intercourse painful for you? ______
108 * Do you have diminished sexual drive? ______
109 * Have you had a hysterectomy? ______
110 * Do you retain fluid during your period? ______
111 * Do you have frequent yeast infections? ______
112 * Problems with fertility? ______
113 * Problems with miscarriage? ______
114 * Morning sickness? ______
115 * Menopause? ______
116 * Premenstrual sickness? ______
117 * Dysmenorrhea? ______
118 * Feminine discharge? ______
119 * Breast cysts, lumps, or mastitis? ______
120 * Excessive appetites? ______
121 * Desire to vomit after eating? ______
122 * Obsessive dietary habits? ______
123 * Other ______
URINARY
124 * Do you have frequent urination? ______
125 * Are you a bed wetter? ______
126 * Have you lost control of your bladder, or dribble when sneezing or laughing? ______
127 * Do you have painful urination? ______
128 * Do you have frequent kidney or bladder infections? ______
129 * Do you have kidney stones? ______
CHILDREN
130 * Bedwetting? ______
131 * Colic? ______
132 * Swollen tonsils? ______
133 * Learning disabilities? ______
134 * Hyperactivity? ______
135 * Teething problems? ______
136 * Other ______
BEHAVIORAL
137 * Nervousness? ______
138 * Agoraphobia: fear of crowds or going out of the house? ______
139 * Claustrophobia: Fear of closed spaces? ______
140 * Depression? ______
141 * Manic depression or severe personality shifts? ______
142 * Any severe mental or emotional traumas? ______
143 * Grief or guilt? ______
144 * Insomnia? ______
145 * Do you feel you are under considerable emotional stress? ______
146 * Do you have any obsessive behavior of any type? ______
147 * Other ______
List all forms of physical traumas, chemical exposures, mental stress as pertaining to your employment, home lifestyle, etc.:
List all nutritional supplements, home remedies, etc. your have tried and their results. List what you are currently taking.
______
Confidential information: Please feel free to write any information that you feel is individually important to your health and well being. This information is necessary for us to provide you with the highest quality care possible.
______
The major health problems of your immediate family will assist us in understanding your health pattern. Report all diseases, sicknesses, reasons for hospitalization, cause and age of death, etc.
Name Relation Health Problems
Please Mark your areas of pain on the figures below:
The information I have provided is to the best of my knowledge, accurate and true.
Date: ______
Signature: ______
Signature of parent or guardian if the Patient is under the age of 18: ______