Health Inventory
Name: ______Date: ______
Who do you live with?
Alone __ Friend(s) __ Partner __ Spouse __ Parents __ Children __ Pets __
Number of Children____
Names and ages of everyone living with you: ______
Pets: ______
Educational Background
High School __ Bachelor __ Master __ Doctorate __ Other __
Employment Status
Full-time __ Part-time __ School __ Retired __ Unemployed __
Occupation ______Employer ______
Hours/Week ______
Current / Recent Health Care Providers
NameAddress DatesCare Provided ______
______
______
______
Does Cara Michele have your permission to consult with your medical physician(s)? ______
Will you need us to provide a monthly statement of your visits to submit for insurance reimbursement? ______
Current Health Concerns
Please identify the health concerns, in order of importance, that have brought you to this office:
Condition______
Past treatment ______
How does this condition affect you? ______
Condition ______
Past treatment ______
How does this condition affect you? ______
Medication Taken
Medications:
______Dosages: ______
______
______
______
Vitamins:
______Dosages: ______
______
______
______
Food Supplements:
______Dosages: ______
______
______
______
What other treatment modalities are you involved with? (For example: chiropractic, herbal, massage, reiki, exercise programs, diet programs, counseling etc.)
______
______
Allergies
Drug allergies______
Allergies to food, pollen, etc.______
Breast Health
Have you ever had a mammogram? ______Dates______Results______
Do you perform breast self-exams? ______
Hospitalizations/Operations
DatesHospitalDiagnosis/OperationDoctor
______
______
______
Pregnancies(including miscarriages and abortions)
DatesHow Far AlongSexWeightProblems
______
______
______
______
Childhood Illness
__Scarlet Fever __ Diphtheria __Rheumatic Fever __ Mumps __Measles
__German Measles __Chicken Pox Other______
Gynecological History
Date last period began______Date prior period began______
Age at first period______
Date of last pelvic exam______Results _____
Date of last PAP smear______Results______
Ever had an abnormal Pap smear?______When______Results______
Treatment______
Family HistoryFatherMother Brothers Sisters Spouse Children Maternal GP Paternal GP
Age (if living)______
Cancer______
Diabetes______
Heart Disease______
High Blood Pressure ______
Stroke______
Mental Illness______
Asthma/Hay fever______
Kidney Disease______
Osteoporosis______
Alcoholism ______
Other addictions______
Other illnesses______
Age (at death)______
Cause of Death______
Diet
Dietary restrictions ______
Sample of day's menu:
Breakfast______
Lunch ______
Dinner______
Physical Exercise
Type of exercise ______
How many minutes______How often ______
Tobacco Use
How much______How long______
Previous use (how much)______How long______
Alcohol Use
How much______How long______
Previous use (how much)______How long______
Caffeine Use
How much______
Mood-altering Substances
Present ______How much______
Past______How much______
Sexual Activity
Are you sexually active? ______Do you have intercourse? ______
Do you practice safe sex? ______Any concerns?______
Are you trying to get pregnant? ______How long? ______
Any history of sexually transmitted diseases? ______
Birth Control
Current birth control method ______How long ______
Any problems with it?______
Past birth control methods: ______
Menstrual Cycle
Number of day from the start of your period to the start of the next______
Number of days of flow?______Amount of bleeding______Amount of cramps______
Premenstrual symptoms______
When do they start?______
Any current changes in your normal pattern?______
Any bleeding between periods______When?______
Any unusually pelvic pain, fullness or discomfort?______When?______
Describe______
Any unusual vaginal discharge or itching?______Describe ______
Review of Symptoms
Check any symptoms of presentsignificance:
Fever or chills__ Hot flashes __ Unusual hair growth __ Skin eruptions __ Weight change __
Bloating __ Heart burn, indigestion __ Cramps or pain __ Nausea or vomiting __
Change in bowel habits__ Bloody stool__ Diarrhea __ Constipation __ Hemorrhoids __
Flatulence__
Headaches __ Dizziness __ Visual defects __ Hearing defects __ Sinus trouble __ Fainting spells __
Frequent urination __ Painful urination __ Blood in urine __ Inability to hold urine __
Inability to empty bladder __ Need to get up at night to urinate __
Chest pain __ Shortness of breath __ Heart skipping a beat __ Palpitations __ Chronic cough __ Coughing up blood __ Wheezing __
Lumps in breast __ Bleeding from breast __ Discharge from breast __ Breast tenderness __
Any other current concerns______
Daily Living Profile
Please indicate yes or no
My neighborhood is too noisy.____
My neighborhood is too crowded.____
My neighborhood is too quiet.____
I do not have enough friends/neighbors.____
I live in a dangerous neighborhood.____
I have too many household tasks.____
The weather bothers me.____
I'm new to this area.____
Any other neighborhood problems______
I'm recently married.____
I'm separated or divorced.____
I have recently moved or am planning to move.____
I am alone too much at home.____
I’m concerned about my relationship with my partner.____
I'm concerned about my relationship with other family members.____
There is a new baby in our family.____
I (or one of my family members) am having legal problems.____
There was a recent death of my family member or close friend. ____
There is a serious illness in my family.____
I am worried about one of my family members.____
Someone close to me drinks or uses illegal drugs too much.____
One of my children has moved away from home recently.____
My partner has recently started a new job or retired.____
Other home concerns______
I'm bored with the work that I do.____
At work, other people make too many demands on me. ____
I have too little control over my work.____
I am not satisfied with the work I do.____
I often feel overwhelmed by my responsibilities. ____
I do not have enough time to complete my work.____
I just began a new job or just lost my job.____
I don't get along with my boss or other employees.____
Other work related concerns______
I worry about money a great deal.____
I feel lonely.____
I am bored with my life.____
I have concerns about my life.____
I think a lot about dying.____
I have concerns relating to my religion.____
Other personal concerns______
I have difficulty falling asleep.____
I have difficulty staying asleep.____
I have difficulty staying awake.____
I often feel depressed.____
I feel nervous the majority of the time.____
I worry a lot.____
I am ill frequently.____
I have considered committing suicide.____
I sometimes feel weak or light headed.____
I often feel like crying.____
I often drink too much alcohol.____
I often overeat. ____
I don’t have a good relationship with food.____
I lose my temper often.____
Other emotional concerns ______
Thank you for your trust and partnership.