Guest guest Posted June 20, 2009 Report Share Posted June 20, 2009 I have found this very handy...................... A doctor sent this questionarie - since these are common questions asked, thought you could save time at the app. by filling this in before seeing new doctor. This would not completely fit on my email - if you would like it , email me and I will send it tback to you. blessings Shan Adult Medical Questionnaire Important Notice: Some of our patients and staff are very sensitive to chemical odors. Please do not wear any perfume, hair sprays, deodorants or other materials that have a scent when you come to the office. Wear no make up and no nail polish. Name: Address: Home Phone: Work phone: Cell phone: Birth Date: Email: Referred by: Occupation: Place of Birth: Ethnic/National/Racial roots: Eye Color: Hair Color at age 15: Hair Color now: Height: Weight: Gender: Right handed? Left handed? Mixed Dominance? # of sisters (# deceased? # of brothers (# deceased)? Birth Order: Note that I am interested in so-called minor symptoms as well as in major problems. I know that in many doctor's offices there is some tendency not to mention too many symptoms for fear that the doctor will take you for a hypochondriac. The rules here are different. I am interested in any message you are getting from your body, even though it may be considered irrelevant to " making a diagnosis " or it may seem to you to be of no consequence to your health. Some such symptoms are useful clues in the kind of medical detective work i do. Please include as much information as you can on this form and the chronological history form (feel free to skip any questions you do not wish to answer) Thank you. Please rank problems by priority # =rank, P= past, L= lab, A= acute, S = a Strength ß Symptom (0= Absent, 3= mild, 6= Moderate, 9=severe, 12= incapacitating.) DATE Example Headache 8 1 2 3 4 5 6 7 A L L P S S (you can add more rows by placing the cursor at the beginning of this line and: <table>,<insert>, <row above> What diagnoses or explanations have been given to you? __________________________ ________ __________________________ ________ What other doctors, clinics or hospitals have you consulted, and when? __________________________ ________ __________________________ ________ Who referred you or how did you hear about us? __________________________ ________ __________________________ ________ If the referring person is a health professional who should receive reports, please give his or her full address: Telephone Number: Personal Descriptive Information: With whom do you live? (Include children, parents, relatives, friends...please include ages ) {Example: Wendy, age 7, sister} ______________________ __________________________ What pets live with you - indoor or outdoors only? __________________________ When and where have you lived or traveled outside of the United States? __________________________ __________________________ Major life changes recent or soon for you or your family? __________________________ __________________________ Please indicate invasive life experiences (traumatic medical, abusive, sexually inappropriate) or losses you have experienced and at what age(s) they occurred. __________________________ __________________________ How important is religion/spirituality in you and your family’s life? __________________________ _________________________ How much time have you lost from work or school in the past year? ____________________ Previous jobs: ______________ __________________________ Where did you go to High School? ______ Leaning problems? _________ College? _______________________ Major ______________________ Year ______ Graduate School? _____________________ Field ______________________ Year ______ Professional School? _____________________ Field ______________________ Year ______ Past Medical and Surgical History: ILLNESSES WHEN COMMENTS Chicken Pox Mononucleosis Measles German Measles Mumps Hepatitis INJURIES WHEN COMMENTS Head Injury Neck Injury Back Injury Broken … Broken … DIAGNOSTIC STUDIES WHEN COMMENTS Chest X-ray Mammogram EKG Sigmoidoscopy Colonoscopy Upper GI Series Barium Enema CAT scan of brain CAT scan of abdomen CAT scan of spine Liver scan Bone scan Neck X-ray OPERATIONS WHEN COMMENTS Tonsillectomy P.E. Tubes in Ears Appendectomy Gall Bladder Hernia Hysterectomy Medications: How many times have you taken: Infancy Childhood Teens Adulthood Antibiotics: ______ ______ ______ ______ Steroids: ______ ______ ______ ______ Dental fillings: Do you have Silver Amalgam (mercury amalgam) fillings in any teeth? _____ Yes ______ No _____ Not sure _____ Yes, but they were all replaced What medications, supplements, therapies are you taking now or taken in the past? Treatment Daily Start Until Comment Eating and Drinking: Question Yes Comment When your mother was pregnant with you did she: Smoke tobacco? Drink alcohol? Take estrogen? Were you a full term baby? A preemie? Breast fed? Bottle fed? Did you live in an area with soft water? Hard water? As a child did you eat a lot of sugar? Candy? Sweet foods? Soda? Diet soda? White bread? Cookies? Ice cream? Meat, vegetable, & potato/rice pasta diet? Vegetable & grain based diet with little meat? Vegetarian diet with milk and eggs? Vegetarian diet without milk and eggs? Drink milk more than once a day? As a child was there any food that you had to avoid because it gave you symptoms - such as milk/gas or diarrhea? (please name the food and symptom. __________________________ ________ What about now? ____________________ Is there anything special about your diet that I should know about? __________________________ ________ Has there ever been a food that you craved or really " pigged out " on over a period of time? (Please indicate what and when). *Food craving is an indicator that you may be allergic to that food. __________________________ ________ Alcohol: Never used _____ Social _____ Alcohol problem from _______ to _______ Was your mother an alcoholic? _______ Father? _______ Other family members? _______ Tobacco: Never used _____ Smoked from age _____ to _____, _____ packs/day Cigars _____ Pipe _____ Snuff _____ Chewing tobacco _____ When used? ____________ Present or Recent Diet: Place a check mark next to the food/drink that applies to your diet. Usual Breakfast Ö Usual Lunch Ö Usual Dinner Ö None None None Eggs Meat sandwich Red meat Bacon/Sausage Fish sandwich Poultry Milk Lettuce Fish Coffee Tomato Green vegetables Tea Mayo Beans (legumes) Toast Leftovers Carrots Bagel Yogurt Yellow vegetables Donut Soup Salad Sweet roll Salad Salad dressing Juice Salad dressing Potato Fruit Coffee Pasta Cereal Tea Rice Oat bran Milk Brown rice Wheat bran Soda Butter Yogurt Juice Margarine Sugar Sugar Coffee Sweetener Sweetener Tea Butter Butter Sugar Margarine Margarine Sweetener Other: (List below) Eat in work cafeteria Soda Eat in restaurant Juice Other: (List below) Milk Other: (List below) Snacks: What snacks do you eat or drink between: Breakfast and lunch? __________ Lunch and dinner? ____________ After dinner? ________________ How much of the following do you consume each day? Daily or Weekly Slices of white bread (rolls/bagels) Cups of caffeine containing coffee Cup of caffeine containing tea Cups of hot chocolate Cups of decaffeinated coffee or tea Diet sodas Sodas with caffeine Sodas without caffeine Candy Chocolate Cheese Sardines Carrots Salty foods Ice cream Past and Present Symptoms Please x the best description of your symptoms (mild, moderate or severe) and indicate the time frame (occasional, frequent or always): Please use lower case x’s to mark this part of the questionnaire. MORE CONTINUED Quote Link to comment Share on other sites More sharing options...
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