Doctor’s name
Address
Phone; fax numbers
Follow-up Health & Environment History Questionnaire
IF YOU CANNOT KEEP YOUR APPOINTMENT, notify our office 48 hours before your appointment day (or even earlier if possible) so that we can try to schedule another patient.
BEGIN QUESTION 6 FIRST, STARTING 4+ DAYS BEFORE APPOINTMENT.
Name: ______Date: ______
Are there any changes to your address or phone number? YES NO
IF YES, please indicate the change here
Address:______Phone____________
______
______
1. Does your current health significantly reduce your ability to do your job, housework, chores, etc?
YES NO IF YES, describe ______
2. Have you seen other doctors since your last appointment with Dr. Ziem? YES NO
IF YES, list the doctor’s name, address, phone number, and medical problem.
______
______
______
3. Have you been hospitalized since your last appointment with Dr. Ziem? YES NO
IF YES, list all hospitals, addresses and dates of hospitalization: ______
______
______
______
- List all medications that you are taking, dose, how often, purpose, whether they help, and side effects.
Bring the medication bottle(s) to your appointment
Medication / Dose/Frequency / Purpose / Helps? / Side Effects
5. For the symptoms and health problems listed below(If you have had the problem in the last year), CHECK
the box that best describes how often the symptom occurs, or CHECK 7 if not sure.
Daily toAlmost Daily / Several Times/Week / Once A Week / Several Times/Month / Once/Month or Less / Rarely If Ever / Not Sure
Headache
Numbness, Tingling
Weakness in a body part
Lightheadedness, dizziness
Tremor or shaking
Muscle twitching
Confusion, spaciness,
inability to concentrate
Memory problems
Slurred words, difficulty
finding words
Dizziness when standing up after sitting
Coordination difficulties
Visual changes
Dizziness when standing up
Itchy, watery eyes or nose
Ringing ears
Nasal symptoms (discharge, stuffiness) burning (circle)
Sinus discomfort
Throat discomfort (soreness, tightness) burning (circle)
Weak voice, hoarseness
Swollen glands
Coughing
Chest discomfort (heaviness, pain) (Circle one)
Chest tightness
Wheezing
Fatigue (unusual)
Muscle discomfort, Spasm
Joint discomfort
Daily toAlmost Daily / Several Times/Week / Once A Week / Several Times/Month / Once/Month or Less / Rarely If Ever / Not Sure
Difficulty or discomfort with swallowing
Reflux of stomach acid
Nausea, vomiting
Bloating, gas
Abdominal discomfort
(pressure, pain, cramps)
Shakiness relieved with eating
Poor appetite
Sweet craving
Rapid pulse Palpitations
(rapid, violent throbbing,
extra, or skipped heartbeats)
Swelling of ankles
Bruising without a cause
Flushing skin
Reduced bladder control
Need to pass urine frequently
Insomnia
Frequent jerking in sleep
Loud snoring in sleep (ask
Spouse)
Stopping breathing in sleep
(ask spouse)
Unwanted falling asleep
during the daytime
Menstrual Changes (women)
Impotence, reduced ability for erection (men)
Significantly reduced sex drive
Pain, burning in genital area
Painful intercourse or other
sexual problems
Symptoms with loud noise,
certain sounds
Eyes very light sensitive
Eyes very dry
Skin very dry
Mouth very dry
Unusual thirst
Cold/heat intolerance
Fingertips turning white or
blue
Other (specify):
6. STARTING 4+ DAYS BEFORE APPOINTMENT, list all you eat & drank, recording after each meal
in a 4 day interval before you appointment. Eat as you would normally.
Breakfast / Lunch / Dinner / OtherDay 1
Day 2Day 3
Day 4
- We will use these questions to evaluate your response to treatment. These questions ask about symptoms you may have experienced commonly. Rate the severity of your symptoms on a 0 to 10 scale: 0=not at all a problem: 5=moderate symptoms: 10=disabling symptoms.
a. Problems with your head, such as headaches, or a feeling of pressure
or fullness in your face or head? 0 1 2 3 4 5 6 7 8 9 10
b. Problems with your ability to think, such as difficulty concentrating
or remembering things, feeling spacey, or having trouble making
decisions? 0 1 2 3 4 5 6 7 8 9 10
c. Problems with your mood, such as feeling tense or nervous, irritable
depressed, having spells of crying or rage, or loss of motivation to do
things that used to interest you? 0 1 2 3 4 5 6 7 8 9 10
d. Problems with your balance or coordination, with numbness or tingling
in your extremities, or with focusing your eyes? 0 1 2 3 4 5 6 7 8 9 10
e. Problems with your muscles or joints such as pain, aching,
cramping, stiffness or weakness? 0 1 2 3 4 5 6 7 8 9 10
f. Problems with your skin such as a rash, hives, or dry skin 0 1 2 3 4 5 6 7 8 9 10
g. Problems with your urinary tract or genitals, such as pelvic pain,
frequent or urgent urination? (for women: or discomfort or other
problems with your menstrual periods?) 0 1 2 3 4 5 6 7 8 9 10
h. Problems with your stomach or digestive tract, such as abdominal
pain or cramping, abdominal swelling or bloating, nausea, diarrhea,
or constipation? 0 1 2 3 4 5 6 7 8 9 10
i. Problems with your heart or chest, such as a fast or irregular
heart rate, skipped beats, your heart pounding, or chest discomfort? 0 1 2 3 4 5 6 7 8 9 10
j. Problems with burning or irritation of your eyes or problems
with your airway or breathing, such as feeling short of breath,
coughing, or having a lot of mucus, post-nasal drainage, or
respiratory infections? 0 1 2 3 4 5 6 7 8 9 10
Research question from Dr. Claudia Miller.
8. Do you have pain once a week or more? YES NO
If Yes, how often? Weekly 2-4times/week Almost daily Other:______
a. How severe is the pain usually? Mild Moderate Severe
b. How long does it usually last? 1 hour or less 2-4 hours 5-8 hours Other: _____
9. Compare your health in the last few months with your health at your last visit with Dr. Ziem?
About the same A little better A lot better A little worse A lot worse
IF WORSE, describe what problems have been worse: ______
______
10. Since your last office visit, describe your reactions:
a. Onset: more delayed as before quicker
b. Duration: shorter as before longer
c. Severity: less as before worse
11. Are you presently working outside the home? Yes No
IF YES, compare your health during the workweek to how you feel at the end of a weekend:
About the same Better Worse
IF NO, did you leave work because of illness? Yes, date left: ______No
12. Does your medical condition interfere with your ability to do any of the following?
If it doesn't apply to you, check "Not Applicable". Also describe any problems.
No /Yes A Little
/ YesModer-ately / Yes A Lot / Not Appli-cable / Describe problems or symptoms, if any:
a. Climbing Stairs?
b. Sitting longer than 1 hour?
c. Standing longer than 1 hour?
d. Frequent bending?
e. Frequent twisting?
f. Thinking clearly while reading?
g. Thinking clearly while doing
simple arithmetic?
h. Remembering and following
instructions?
i. Writing/typing over 1 hour?
j. Driving a car in heavy traffic?
k. Household chores?
Scrubbing floors
Washing windows/car
Vacuuming/sweeping
l. Carrying groceries? 10-15 lbs
m. Going to public places?
No / YesALittle / Yes
Moder-ately / Yes A Lot / Not Appli-cable / Describe problems or symptoms, if any:
n. Frequent lifting 5-10lbs?
- Frequent walking (short
p. Interacting with people?
q. Maintaining regular work
schedule?
13. Do you usually buy foods grown without pesticides (organic)? Yes No Not Sure
- Are you currently using a filter device containing activated charcoal (be sure it contains charcoal before
checking YES. (DO NOT USE OZONE GENERATING FILTERS!)
Yes No Don't Know Brand
a. Car? ______
b. Bedroom? ______
c. Shower/Bathing area? ______
d. Entire house water supply? ______
e. Drinking water? ______
f. Other home areas? ______
15. Are you doing sauna treatments following exercise?
No Yes, at home (brand ______)
Yes, commercial sauna Yes, sauna at medical facility
F YES, Average number of times weekly: ______
What year did you begin regular use? ______
16. Have you gone through all personal and household products to determine which ones
have pesticides, other petrochemicals, or irritating substances? Yes No
17. Is your current heat: Electric Natural Gas Oil Other: ______
- Do you have a gas stove, water heater, or dryer?
No Stove Water heater Dryer
19. Have you changed your mattress, pillow, bedding to all cotton? Yes No
20. Do you feel you have current workplace exposures which seem to be aggravating your
condition? Yes No Not Sure Not Applicable/ Not working
IF YES, please list:
______
______
21. Are any chemical pesticides (excluding boric acid) used?
Yes No Don't Know
a. In your home? ______
b. On your job? ______
- Do you have any neighbors who use outdoor pesticides frequently or in large amounts?
Yes No Not Sure
23. Are you around any other neighborhood exposures that concern you or make you
sick? No Yes, of concern Yes, seems to make me sick IF YES, describe:
24. Do you have a humidifier at home? Yes No
IF YES, does the water go through a charcoal filter first? Yes No Not Sure
25. Describe important things that have happened to you since your last visit with us:
Major exposures, reactions, other problems not detailed in you answers so far. Use extra
paper if needed.
______
______
______
______
26. Describe a typical reaction, listing symptoms in order of onset, and describing the time frame.
If your reactions are quite different from time to time, describe this also.
______
______
______
______
27. Describe your activities for a relatively typical day in the past month, and indicate how this
differs from your last visit, if any.
______
______
______
______
28. What other problems do you face with your health, if any: physical, emotional, social,
financial, sexual, legal, etc.
______
______
______
______
29. Make a list of your questions and your goals for this visit. Use extra paper if needed.
Questions: ______
______
______
______
______
Goals: ______
______
______
______
______
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