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Patient Form dates: ________________________________.. What would you like to be treated for:. Diabetes, High blood pressure, cancer, Heart disease, Kidney disease. Do you have allergies?. How many meals per day do you eat?. What other beverages do you drink?.
Patient Form dates: ________________________________.. What would you like to be treated for:. Diabetes, High blood pressure, cancer, Heart disease, Kidney disease. Do you have allergies?. How many meals per day do you eat?. What other beverages do you drink?.
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Patient Form dates: ________________________________.. What would you like to be treated for:. Diabetes, High blood pressure, cancer, Heart disease, Kidney disease. Do you have allergies?. How many meals per day do you eat?. What other beverages do you drink?.
Авторское право:
Attribution Non-Commercial (BY-NC)
Доступные форматы
Скачайте в формате DOC, PDF, TXT или читайте онлайн в Scribd
General Information _________________________________________
First Name: _________________________________________ _______________________________ _________________________________________ Last Name: ___ _______________________________ List all medications and supplements you Address: are currently taking: _________________________________ _________________________________________ City: _________________________________________ _____________________________________ _________________________________________ State: ___________ Zip code: _________________________________________ ________________ ____ Email: ___________________________________ Any long term or frequent use of Home Phone: antibiotics? _____________________________ _________________________________________ Cell Phone: _ _______________________________ Do you have allergies? _______ Describe: Age: _________ Birth Date: _____ _________________ _________________________________________ Occupation: Digestion/Nutrition ______________________________ How is your appetite? Emergency contact: _____________________ ________________________ Check any issues that apply to you: Phone: □ Constipation □ Loose stools □ ___________________________________ Bloating Primary Physician: □ Gas □ Acid reflux □ Abdominal ________________________ pain Phone: ___________________________________ How many meals per day do you eat? What would you like to be treated for: _______ 1. Are you thirsty? ________________________________________ ___________________________ 2. How much water do you drink per day? ________________________________________ _____ 3. Do you prefer cold or hot beverages? ________________________________________ ________ Do you drink caffeinated beverages? Health History _________ Have any of your blood relatives suffered How many per day? from any of the following (please check): _______________________ □ Diabetes □ High blood pressure □ Do you drink alcohol? Stroke _____________________ □ Cancer □ Heart disease □ Kidney How much? disease ______________________________ List other beverages including juice, rice List major events of your health history milk, almond milk, soy milk, tea, etc. you (illnesses, surgery, accidents, drink; hospitalizations, heavy metal or toxin exposure, etc.): _________________________________________ If not, describe: _________________________________________ ___________________________ __ _________________________________________ What dairy products do you eat? _ ____________ How many hours do you sleep in _________________________________________ general? ___ _ Have lots of dreams? Are you a vegetarian or vegan? ______________________ _____________ Do you feel rested when you wake? List sources of meat/protein: _________ ________________ What is your energy level in general on a _________________________________________ scale of 1-10 (10 being best)? _ _____________________ _________________________________________ _ Exercise/Lifestyle List any food allergies or sensitivities: Do you exercise? _____ How often? _______ __________ _________________________________________ What kind of exercise? _ _____________________ What % of your diet is organic? _________________________________________ _____________ _ Do you have any particular cravings? How long do you exercise for? ________ ______________ Please specify Do you like to exercise? _____________________________ ____________________ Times per week you eat out? Any awareness practices (meditation, ________________ prayer, affirmation, or other practices)? Eat regularly at fast food restaurants? _____________ ________ _________________________________________ Do you eat a lot of processed food? _ __________ Hours of TV you watch daily? Do you eat late at night? ______________ ___________________ Hours spent at the computer daily? Do you chew your food thoroughly? __________ _________ Pain Do you think you get enough fresh fruits, Describe any pain, stiffness, or swelling vegetables, and whole grains daily? in your body: _________ ____________________________________ How would you describe your diet: _________________________________________ □ Unhealthy □ Fair □ Good □ _________________________________________ Fantastic __ How would you rate your cooking skills Do you suffer from migraine or tension on a scale of 1-10 (10 being best)? headache? _______ How often? ________________ _____________ Are you ready and willing to make Do you have any: changes in your diet if need be? □ Dizziness □ Chest pain □ _______________________ Palpitations Sleep □ Floaters in eyes □ Burning, red, itchy Do you sleep soundly? eyes _____________________ Skeletal Any broken bones or fractures? Any problem with ED? _____________ ____________________ How many? _____ Osteoporosis? Difficult urination? ____________ ________________________ Libido good? Teeth _____________________________ Have you had lots of cavities? Other issues: ______________ ______________________________ Any root canals? _____ Gum disease? ________ Urination Ringing in ears? _______ TMJ? Is your urine clear like water?____ cloudy? ______________ ___ Scanty? ____ Yellow? _____ Dark yellow? Emotions (check all that apply to you): ____ □ Anger □ Depression □ Worry □ Do you get up at night to urinate? Anxiety ___________ □ Sad □ Fearful □ Happy □ Other How many times? __________ _________________________ Women’s Health Body Temperature Are your periods regular? Feel cold often? ____ dislike the cold? ____ __________________ Feel hot often? ____ dislike the heat? ____ Check all that apply to you: Have afternoon flushes/fevers? □ Painful periods □ Heavy flow □ ______________ Scanty flow Night or daytime sweats? □ Clotted □ PMS □ Breast tenderness □ __________________ Fibroids □ Hormonal migraine □ Endometriosis Thank you for taking the time to □ Vaginal discharge □ Chronic UTI’s complete this form. If you have any □ Birth control pills □ Other questions regarding filling out this ________________ form, please call Ellie at (847)864- _________________________________________ 6464. If you have more information _ you think I need to know, please use How many pregnancies? the backside to write on. ___________________ Any miscarriages? _______ How many? ______ Are you currently undergoing fertility treatment? ________ Please describe: _________ _________________________________________ _________________________________________ __ Have you started menopause? ______________ Any problematic issues related to menopause? _________________________________________ _________________________________________ __