Dr. Ameet Aggarwal, ND P.G. Gestalt PsychotherapyNaturopathic Medicine

Tel: 0727 701002, P.O. Box 275, NanyukiGestalt Therapy

Email: Bowen Therapy

PERSONAL HISTORY FORM

(Confidential)

Personal Health History

Today’s Date:___/___/___

Name______Age____Male__Female__ Date of Birth ___/___/___

Home Address:______

Home Phone______Work Phone______Email______

Occupation______Extent of Travel______

Spouse’s Name______

Children’s Names______Ages______

If patient is a child, parents’ names______

Number of visits to another health care practitioner this year____

Names of other Healthcare providers______

How did you hear about us? ______

Your Main Health Concerns (list in order of priority)

1.______

2. ______

3. ______

When did your problem begin?______

What measures have you taken to improve your problems?______

______

Please list any current medications you are on, including vitamins/supplements______

______

Lifestyle

Cigarettes smoked per day?______

How much coffee, tea or cola do you drink per week?______

How much alcohol do you drink per week?______

Diet

BreakfastLunchDinnerSnacks

Past Medical History

Hospitalization and/or surgeries______

Significant traumas (auto accidents, falls, etc)______

Allergies(drugs, chemicals, foods)______

Childhood diseases______

Current Symptoms (Please write P (if had in past), or 1-4, 1=mild 4=severe, or give details)

GENERAL

Weight_____Fatigue / Energy drop_____Mood swings_____

Weight 1 year ago_____Poor sleep_____Phobias_____

Any weight loss_____Fevers/Chills_____Fears_____

Cravings (food, etc)_____Sensitive to hot/cold_____Alcohol/Drug Abuse_____

Strong thirst (cold or hot?)_____Sweats easily_____

Peculiar taste/smell (when?)_____

SKIN AND HAIR

Rashes/Hives_____Acne/Boils_____Eczema/Itching_____

Recent moles/changes_____Colour changes_____skin cancer_____

Dandruff_____Loss of hair_____Change of hair/skin texture_____

Any other skin issues_____Nails changes/dryness_____Temperature change_____

HEAD, EYES, EARS, NOSE AND THROAT

Headache_____Redness_____Stuffiness/Hay fever_____

Migraine_____Itching_____Recurrent sore throats_____

Dizziness_____Tearing_____Loss of taste_____

Concussion/Head injury_____Dryness of eyes_____Gum problems_____

Impaired/double vision_____Eye discharge_____Teeth problems_____

Glasses/Contacts_____Ear discharge_____Grinding Teeth_____

Blind spots_____Impaired hearing_____Facial pain_____

Spots in front of eyes_____Ringing in ears_____Hoarseness_____

Night blindness_____Earaches_____Swollen glands_____

Cataracts_____Ear infections_____Goiter_____

Glaucoma______Nosebleeds_____

Eye pain______Frequent colds_____

CARDIOVASCULAR

Heart Disease_____High blood pressure_____Swelling of hands/feet_____

Irregular heartbeat_____Low blood pressure_____Cold hands/feet_____

Palpitation/fluttering_____Dizziness/Fainting_____Cyanosis/Blueness_____

Chest pains_____Phlebitis_____Bleed or bruise easily_____

Rheumatic fever_____Blood clots_____Anemia_____

Past transfusions_____Lymph node swelling_____Bleeding gums_____

RESPIRATORY

Asthma_____Tuberculosis_____Difficulty breathing_____

Bronchitis_____Cough_____Wheezing_____

Emphysema_____Coughing blood_____Shortness of breath_____

Pneumonia_____Phlegm (what colour)_____Difficult breathing if lying down__

Pleurisy_____Pain with deep breath_____

GASTROINTESTINAL

Ulcer_____Rectal Pain_____Gas_____

Crohns_____Vomiting(blood?)_____Constipation_____

Celiacs disease_____Nausea_____Chronic laxative use_____

Liver disease_____Indigestion_____Diarrhea_____

Gallbladder disease_____Poor appetite_____Blood in stools_____

Ulcerative colitis_____Change in appetite______Black stools_____

Hernias_____Change of thirst_____Rectal bleeding_____

Heartburn_____Belching_____Food allergies_____

Hemorrhoids_____Bad breath_____Abdominal pain or cramps_____

GENITOURINARY

Frequent urination_____Unable to hold urine_____Blood in urine_____

Urgency to urinate_____Pain on urination_____Kidney stones_____

Decrease flow_____Impotency_____Sores on genitals_____

Do you wake to urinate_____Particular colour of urine____Frequent infections_____

PREGNANCY AND GYNECOLOGY

Age at first menses_____Pain during intercourse_____Vaginal discharge_____

First date of last menses_____Difficulty conceiving_____Vaginal sores_____

Days between menses_____Number of pregnancies_____Vaginal itch_____

Duration of menses_____Number of live births_____Last PAP smear_____

Menses: Heavy, light, spotting?Premature births_____Changes in body/psyche in menses_

Painful periods_____Abortions_____Breast lumps_____

Irregular periods_____Miscarriages_____Breast pain/tenderness_____

Clots_____Birth control type_____Nipple discharge_____

Endometriosis_____Cervical dysplasia_____Uterine fibroids_____

MALE REPRODUCTIVE

Hernias_____Sexual difficulties_____Prostate infections_____

Testicular pain_____Venereal disease_____Prostate cancer_____

Testicular masses_____Discharge or sores_____Last prostate exam_____

MUSCULOSKELETAL

Neck pain_____Back pain_____Arthritis_____

Shoulder pain_____Knee pain_____Joint swelling_____

Hand/wrist pain_____Foot/ankle pain_____Broken bones_____

Muscle spasms or cramps_____Muscle weakness_____Any other joint or bone issues_____

NEUROPSYCHOLOGICAL

Anxiety_____Dizziness/fainting_____Involuntary movement_____

Quick temper/irritable_____Seizures_____Areas of numbness_____

Emotional problems_____Concussion_____Poor memory_____

Depression_____Loss of balance_____Speech problems_____

Easily susceptible to stress_____Lack of coordination_____

Ever considered suicide_____Paralysis_____Any other neurological problems___

Some Things to Ponder

If you could break any rule and there were no consequences, what rule would you break?

Are you in a relationship, and if so, are you happy? If not, do you wish you were?

Do you love your job? Do you feel you’re in touch with your life’s purpose? Do you have a calling, and if so, what is it?

If your health condition had a message to teach you, what is it here to teach you?

What does your body need in order to heal?

Any other problems you would like to discuss:

INFORMED CONSENT FOR TREATMENT

Obtaining an informed consent form is necessary to ensure that you are aware of the treatments being offered and that you are aware of possible side effects. Since each individual reacts differently to therapy, it is not possible to predict all risks and reactions.

By signing this informed consent form,

I ______understand that the treatments being provided to me or the person named below for whom I am legally responsible may include:

Acupuncture, homeopathy, herbal medicine, diet and nutritional counselling, lifestyle counselling, Gestalt psychotherapy and/or Bowen therapy, and I hereby request and consent to the performance of the above treatments on me.

I also understand that there may be certain reactions to certain therapies and supplements, including herbal medicines and I understand that the instructions of using nutritional supplements, herbal medicines or homeopathic medicines will be provided orally or in writing. I am aware that certain therapies may cause adverse reactions, including, but not limited to, allergic reactions to supplements, spontaneous miscarriage, aggravation of symptoms, pain, bruising or slight discomfort from acupuncture, and feeling of faintness or light headedness. I understand that certain nutritional supplements and herbs may be toxic in large doses and may be inappropriate to use during pregnancy. I will notify the person treating me if I am or become pregnant and will immediately notify them of any unanticipated or unpleasant effects associated with any treatments.

Even though this document describes the major risks of treatment, I am aware that other side and risks may occur. I am aware of these risks, and have discussed any concerns I may have regarding treatments and my therapy. I do not expect the clinician to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinician to exercise judgement during the course of treatment which they think at the time, based upon the facts then known is in my best interest. I understand results are not guaranteed.

I am consenting to the treatments offered by Ameet Aggarwal ND or by his fellow clinicians or clinical staff and to treatments recommended by them as well. I have been told about the risks and have had an opportunity to ask questions.

I am also aware that all information provided by myself remains strictly confidential and will only be revealed through written request by myself or where required by law.

I am also aware of the policy that because my appointment time is reserved exclusively for me, any cancellations to my appointment must be made before 5pm the previous day and before Saturday 12pm for Monday appointments otherwise full charges will apply.

I agree that this form holds valid for both present and future treatments for any future condition(s) for which I seek treatment.

______

Patient Name Signature of Patient/Guardian Date