Name________________________________ Nickname (If preferred)__________________ Date of Birth___/____/____
Age______ Female / Male Current weight_______ one year ago______ Maximum weight________ Height_________
Drug allergies_______________________________________________________________________________________
Reasons for this visit- please include your most important health concerns in order of significance:
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ List ALL Prescription and non-prescriptionoral, nasal, inhaled and topical medications with dosages as you ACTUALLY
take them (250mg once daily, 100mg twice weekly, 2-3 10mg tablets 3 days a month as needed for pain/headaches,
etc) Please include medications like Tylenol, Ibuprofen, Aspirin, Miralax, Nasal Sprays (Nasacort, Flonase, isotonic
saline) skin creams/ointments/gels with the name and percentage of the active ingredient, even if you only use them
occasionally. If you run out of space or time or do not understand the labeling - bring all medications with you.
__________________________________________________________________________________________________
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List ALL supplements, herbs, vitamins, minerals, homeopathics, protein/fiber/green powders as you ACTUALLY take
them. For complex formulas (more than 2 ingredients), include the BRAND and product name or bring the bottle with
__________________________________________________________________________________________________
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Please circle any of the following that you use:
Coffee/black tea/cola_____ /day/wk/mo Milk(type_______) Sweetener (type_________) Flavoring(type __________)
Alcohol ______/day/wk/mo Wine/Beer/Spirits Recreational drugs_____day/wk/mo (type___________# years____)
Nicotine _____/day/wk/mo Cigarettes/Nicotine gum/Patch (_____#/day) Total # years of cigarette smoking________
Dietary regimens or restrictions : gluten-free/wheat-free/dairy-free/vegetarian/vegan__________________________
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Food allergies, sensitivities, diagnosed or suspected:_______________________________________________________
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Exercise regularly: Yes No Types:______________________________________________________________________
How often?_____________________________________For how long?________________________________________
CIRCLE symptoms you experience regularly. Women: X CHECK if they occur near or with your period where applicable.
__ chocolate __coffee __Alcohol __ other_____
__Excessive sweating __Watery/itchy __Chest pain
Sleep Hygiene: Use of sleep aid? Yes No Type____________________ How often?___________________________
(If you use a sleep aid, please fill out according to how you sleep with a sleep aid, then explain in space below how you
sleep without an aid)
# of hours per night of actual sleep on weekdays_______ on weekends______ # of hours ALLOWED for sleep on
Weekdays______ on Weekends_______ How long does it take to fall asleep?_______Wake during the night? Yes No
Approx. # of times________ How long awake during these times? Approx. _________ # of times night sweats
wake you up_______ #of times you wake needing to urinate______ I only wake up from: family/pets/noise
How is your sleep without an aid:_______________________________________________________________________
Use of (Circle) TV/Computer/iPAD/Messaging device before bed or when trying to go to sleep
Room completely dark when going to sleep (circle: street lights, floodlights, nightlights, clock lights)? Yes No
Wear an eye mask/earplugs? Yes No What time do you go to bed?_________ What time do you get up?_________ Menstrual and Reproductive History: (This page, females only)
Age of first period___ Using a birth control method now? Yes No Type?______________________________________
Trying to get pregnant? Yes No #of pregnancies____ #of miscarriages____ #of abortions ____ #of cesareans____
#of ectopic/tubal pregnancies____ #of stillbirths____ #premature deliveries ___#of living children___ Ages_________
What birth control have you used: circle type used in the past, add year and duration: Pill_________ Depo shot______
IUD (Mirena/other________)___________Patch__________ Vaginal ring_________ Emergency contraception________
Problems with any of the methods? Yes No If yes, please explain?__________________________________________
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Current or past fertility treatment? Yes No Past use of bioidentical hormones? circle all that apply, add year/duration
DHEA____________________ Biest_____________________Estradiol___________________ Estriol________________
Progesterone__________________________ Pregnenolone__________________ Testosterone___________________
__________________________________________________________________________________________________
Have you had a hysterectomy? Yes No Date___________Reason?__________________________________________
Do you still have ovaries? None One Two Uterine Ablation? Yes No Date_________________________________ Circle all that apply, current and past: Fibrocystic breasts Breast cancer Osteoporosis/Osteopenia Lichen Sclerosis
Uterine fibroids Endometrial hyperplasia Endometriosis Ovarian cysts PCOS (polycystic ovarian syndrome)
Vaginal yeast infections Bacterial vaginosis Gonorrhea Chlamydia Trichomonas Genital herpes Genital warts
Last PAP_______________ Dates of abnormal results: __________________ Dates of treatment ___________________
History of HPV ? Yes No Type_______________ HPV Vaccine? (Gardasil) Yes No
For other PMS or menstrual related symptoms not listed or other unique symptoms, please list them here: __________
__________________________________________________________________________________________________
Menstrual details: Last menstrual period (date of first day of bleeding)___________ or # of years since last period____
Tubal ligation? Yes No Date_________ how many days is your current cycle? (count from the 1st day of bleeding to
the 1st day of bleeding of the next cycle) circle: <20 20-30 30-40 40-50 >50 Is your cycle predictable? Yes no
How many days do you bleed?________ How many heavy days of bleeding?_____ # of tampons and/or pads (circle)
on heavy days___________/______________ on light days _________________/_________________
Color of flow: Bright red Dark red Light red Pink Brown Spotting only (circle) Do you pass clots? Yes No
Size of clots(circle): grainy pea nickel quarter golfball egg lemon How many days do you pass clots?________
Medical History:
Surgeries, hospitalizations, Emergency room visits and other procedures(include approximate dates and chronology):
Last: Colonoscopy_________Prostate exam__________ Mammogram___________DEXA___________ EKG___________
_______________________ _______________________ ______________________ ______________________
Current Medical diagnoses: _______________________ _____________________ _______________________
_______________________ _______________________ _____________________ _______________________
_______________________ _______________________ ______________________ ______________________
Personal medical history and Family medical history (blood relatives only):
Self Past Family Relation to you Self Past Family Relation
Alcoholism/drug use ___ ___ ___ __________ Anemia ___ ___ ___ ___________
Asthma ___ ___ ___ __________ Allergies ___ ___ ___ ___________
Arthritis ___ ___ ___ __________ Auto-immune disorder ___ ___ ___ ___________
Bladder disease ___ ___ ___ __________ (type________________________________________)
Cancer ___ ___ ___ __________ Celiac disease ___ ___ ___ __________
(types_____________________________________) Crohn’s/Colitis ___ ___ ___ __________
Depression ___ ___ ___ __________ Diabetes (Type 1 type 2) ___ ___ ___ ___________
Diverticulosis/itis ___ ___ ___ __________ Epilepsy/Seizures ___ ___ ___ ___________
Gall stones/disease ___ ___ ___ __________ Gum disease ___ ___ ___ __________
Heart Disease ___ ___ ___ __________ High blood pressure ___ ___ ___ __________
Hepatitis A B C (circle)___ ___ ___ ___________ Kidney disease/stones ___ ___ ___ __________
Lung disease ___ ___ ___ ___________ Liver disease ___ ___ ___ __________
Mental disorder ___ ___ ___ __________ Mononucelosis/EBV ___ ___ ___ __________
(type________________________________________) Obesity ___ ___ ___ __________
Rheumatic fever ___ ___ ___ __________ Stroke ___ ___ ___ __________
Suicide attempt(s) #________ ___ __________ Thyroid disease ___ ___ ___ __________
Date(s)_______________________________________ Tuberculosis ___ ___ ___ __________
Tumor ___ ___ ___ ___________ Tumor discovery date________Treatment__________
Other personal and family medical history not listed or previously stated_______________________________________
__________________________________________________________________________________________________
Last dental exam____________ How often do you: Floss_________? See the dentist?______ Metal fillings? Yes No
Gingivitis/periodontal disease? Yes No Root canals? Yes No #_____ Other_____________________________
Immunizations: (circle) DTaP MMR Polio Varicella “Flu” (last ______) Hepatitis B Hib Pneumococcal Other_________
Additional information:_______________________________________________________________________________
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La fièvre et la prise de la température La fièvre et la prise de la température Faits saillants • Les bébés de moins de 6 mois devraient voir le médecin lorsqu’ils font de la fièvre. • N’utilisez pas de thermomètre au mercure. S’il brisait, vous risqueriez d’être exposé(e) à cette substance toxique. • Le degré de la fièvre ne vous indique pas la gravité de la