Select Your Practitioner* John Redden Tiffany Wyse
Tell us about yourself Full name*
Address
Home phone/ best number to reach you
Work or other phone
Email
Can messages be left confidentially? Age
Date of birth
Identify As - please specify, if other* Sex Assigned at birth - please specify, if other* Height
Weight
Education
Marital status Live with Occupation
Hours per week
Do you have extended medical insurance? Person to notify in an emergency?
Relation
Phone
Address
How did you hear about this clinic?
Main reason(s) for visit? (Diagnosis, Chief Complaints & Symptoms)
List as many as you can in order of importance and length of time you have had each symptom.
Other health issues
Do you have any known contagious diseases at this time? If yes, what?
Are you currently receiving healthcare? Other health care providers Please note which of the following types of health care practitioners you have seen in the past What type of Medical Doctor have you seen in the past?
Please note which of the following types of health care practitioners you are currently seeing What type of Medical Doctor are you seeing?
Western Medical Diagnosis known (please include any significant lab reports)
Other diagnosis
Current medications Do you take or use any of the following Please list any prescription medications or over the counter medications you are taking Please list any prescribed medication that you have had an adverse reaction to Current supplements Do you take or use any of the following Please list any vitamins or other supplements you are taking Health history Have you ever been diagnosed or experienced symptoms of the following? Blood Type (if known) A AB B O
Rh factor + -
Chronological Health History Childhood health history
Puberty health history
Adulthood health history
Elder health history
What was your mother’s state of health during her pregnancy with you? If you know, please describe
How was your birth? Any complications? Any interventions (forceps, C-section, epidural, anesthesia, etc.)
Were you breastfed at all? If yes, for how long?
Hospitalizations/ Surgery/ Imaging Any hospitalizations, surgeries, x-rays, CAT scans, EEG, EKGs, blood tests, etc. ? Immunizations Have you had any of the following immunizations: If 'other' selected, please explain
Immune system Have you ever been diagnosed with any of the following terms? If 'other' selected, please explain
Please explain if you have ever experienced allergies, cold/flu, delayed healing, fatigue, sore throat, low grade fever
Please write if these symptoms are often, sometimes or never.
Childhood diseases and syndromes Please select any of the below diseases you have experienced If 'other' selected, please explain
Family medical history Please note any Severe Medical Conditions of close family members: parents, grandparents, children, sisters, brothers, aunts and uncles. Please include the age and health condition of each family member listed.
For example, a history of any of the following: Cancer, Diabetes, Heart Disease, High Blood Pressure, Kidney disease, Epilepsy, Arthritis, Glaucoma, Tuberculosis, Stroke, Anemia, Mental Illness, Asthma Member Age Health Condition
Any other relevant family history?
What is your family heritage?
General health Are you satisfied with your energy levels? Please describe
When during the day is your energy the best and worst?
Have your energy levels changed markedly? Do you exercise? If so, what kind and how often?
Do you watch television or use a computer? If so, what kind and how often?
Do you read? If so, how many hours per week?
Do you have a religious or spiritual practice? If so, what kind (Prayer, Meditation, Temple, Yoga, etc…)?
Body Temperature Please explain what areas of your body might usually feel hot or cold?
For example, please write if any of these body parts may feel hot or cold: general body, arms, hands, palms, fingers, legs, feet, genital region, head, chest, stomach, other
Please explain which weather conditions you like or dislike
For example, do you like or dislike hot, very hot, cold, very cold, dry, damp or humid weather?
Emotional Please check off the emotions you feel the most often If other, please explain
Please check off the emotions you sometimes feel If other, please explain
Please check off the emotions you never feel If other, please explain
Are you an extrovert or introvert?
How would you describe your emotional health?
Memory and concentration How is your long term memory? How is your short term memory? Has your memory changed noticeably in the past few years?
How is your concentration? Has it changed? If so, when and in what way?
Headaches Do you ever have headaches? Please comment on which conditions below you feel the most often If other, please explain
Please comment on which conditions below you sometimes feel If other, please explain
Please comment on which conditions below you never feel If other, please explain
Which are your favourite hours to sleep?
Generally, how many hours of sleep do you need to feel rested?
Do you feel rested when you wake in the morning?
Dreams Please select which of the dreams do you have often? If other, please explain
Please select which of these dreams do you sometimes have? If other, please explain
Please select which of these dreams do you never have? If other, please explain
Skin Please explain which skin conditions you currently or previously had. If you are unsure, please write 'unsure' next to the condition.
For example, Acne, Boils, Brittle, Cracking nails, Bruise easily, Dry Hair, Dry skin, Eczema, Hair Loss, Impetigo, Itchy, Lines, Ridges on nails, Moles, Oily hair, Oily skin, Pimples, Psoriasis, Rashes, Scars, Sensitive to Chemicals, Skin tags, Slow to Heal, Varicose veins, Hot, Cold, Wet, Dry, etc.
Eyes, Ears, Nose, Mouth and Throat Eyes Have you ever been diagnosed with any of the following? Do you wear corrective lenses/glasses? Does the prescription for these change often? Please explain if you have any eye conditions, both previously and currently. If you are unsure, please write 'unsure' next to the condition.
For example, blurred vision, eye pain, spots in front of eyes, etc.
Date of last eye examination
Ears How often, sometimes or never do you have ear conditions?
For example, do you often, sometimes or never have earaches, ear infections, hearing loss, overly sensitive, tinnitus/ringing, wax build up, etc.
How is your hearing? Has it changed in the past years? Please explain
Nose, mouth and throat How often, sometimes or never do you have these conditions listed in the description box
Bleeding gums, Canker sores, Cavities, Constant dryness, Difficulty swallowing, Excess saliva, Grinding teeth, Lip sores, Loose teeth, Loss of sense of smell, Mouth sores, Mucous in throat, Oral herpes/Cold sores, Sinus congestion, Sore gums, Sore Throats, Painful/Tight/Clicking jaw, Swollen glands, Swollen tongue, etc.
Cardiovascular health Have you ever been diagnosed with any of the following? Please select Do you ever experience any of the following? If so, please select If 'other' selected, please explain
Endocrine system Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences
Thyroid problems, Intolerance to heat or cold, Excessive thirst, Easy weight gain, Hard to gain weight, Light Headedness/Dizziness, Irritability/Disoriented, Hot Flashes, Sweatiness, Sudden Energy Drops, your symptoms when missed a meal
Musculoskeletal system Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences
Joint pain, Muscle pain, Muscle weakness, Neck pain, Stiffness, Swollen joints, Other
Have you had an injury or surgery on bone, muscle, tendon, cartilage or related issue?
Do you have any pins or other such items still? If so, when and where?
Respiratory system Have you ever been diagnosed with any of the following? If so, please select Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences
Asthma, Bronchitis, Chest pain or pain when breathing, Common cold, Coughing, Difficulty smelling, Fluid in lungs, Hayfever, Respiratory inflammation, Runny nose, Shortness of Breath, Sneezing, Stuffy nose, Tight around lungs, Trouble breathing in, Trouble breathing out, Wheezing, Other
Have you identified foods, environmental factors or situations that worsen your breathing? If so, what are they?
Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences with mucous
How often, sometimes or never is your mucous:
Clear, Green, Yellow, Thick/Sticky, Thin/Runny
Is your mucous worse in the morning, afternoon, evening and/or night?
Is there a season where you suffer more?
Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences with a cough
Bloody, Dry cough, Hacking, Itchy throat, Painful, Persistent, Regularly, Wet cough
Is your cough usually worse in the morning, afternoon, evening and/or night?
Do you know of anything that triggers the cough?
Urinary system Have you ever been diagnosed with any of the following? If so, please select Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences
Blood in urine, Burning urination, Frequent urge to urinate, Kidney pain, Lower Back Pain, Strong smelling urine, Water retention, pain when urinating, inability to hold urine, Other
Approximately how many times a day do you urinate?
Describe your urine. What colour is it?
Is it cloudy or clear?
What does your urine smell like?
Do you wake up at night to urinate?
After urinating, does it feel like you still have urine in your bladder?
Have you had urinary tract infections? How often?
Gastrointestinal system Digestion Have you ever been diagnosed with any of the following? If so, please select Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences
Abdominal cramps, Alternating constipation/diarrhea, Bladder & Kidney infections, Bloating, Burping, Changes in bowel habits, Chronic abdominal pain, Constipation, Diarrhea, Difficulty Belching, Difficulty gaining weight, Difficulty losing weight, Dysentery, Eating Disorders, Fatigue after eating, Flatulence/Gas, Food allergies, Food unappetizing, Foul smelling stool, Fullness long after meals, Frequent infections (colds), Headaches after eating, Heartburn, Hemorrhoids/Rectal Pain, Indigestion, Indigestion 1-3hrs. after eating, Intolerance to greasy food, Large Appetite, Liver problems, Lower bowel gas, Nausea, Pain in right side under rib cage, Poor appetite, Sour taste in mouth, Stomachaches, Stomach Pains, Stomach Pains after meals, Stomach upsets easily, Stool poorly formed, Sudden acute indigestion, Sudden Weight Change, Ulcer, Vomiting, 3 or more large bowel movements a day
Bowel movements Please check the symptoms that pertain to you If 'other' selected, please explain
How many times a day do you have a bowel movement/defecate?
Is your need to defecate urgent?
Diet Special Diets: current and/or previous (Blood Type, Diabetic, Celiac, Paleo, GAPS, Vegetarian, Vegan, etc…)?
What are your favourite and least favourite foods?
What food did you have yesterday? Please list breakfast, lunch, dinner, any snacks and drinks
* Please fill out the diet and activity report attached to these forms * Nervous system and stress *If you have severe anxiety LINK to Hamilton test*
http://psychology-tools.com/hamilton-anxiety-rating-scale//
https://www.outcometracker.org/library/HAM-A.pdf
Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences
Anxiousness, Bipolar, Butterflies in stomach, Cannot stay asleep, Constant feeling of stress, Depression, Diminished taste, Fear of facing a new day, Fluctuating vision, Hard to concentrate, Involuntary spasms, Mania, Memory loss, Nervousness, Numbness, Panic attacks, Pain – constant, Seasonal Affective Disorder, Seizures, Sudden Mood Swings, Trouble Falling Asleep, Twitching , Worsening coordination/balance, foggy/spacey feeling, Irritable, Other
Describe your stress levels on a scale of 1 (not stressed) to 10 (really stressed)
What goes wrong with your body when stress levels are elevated?
Please list the five most significant stressful events in your life Reproductive System Have you ever been diagnosed with any of the following? If so, please select If 'other' selected, please explain
MALE Have you been diagnosed with any of the following conditions? If so, please select Please comment on the conditions listed in the description box as to how often, sometimes or never you have these experiences
Blood in semen, Blood in urine, Difficulty getting urine flowing, Dribbling, Erectile dysfunction, Excessive sexual thoughts, Frequent urination, Impotence, Interrupted flow of urine, Low back pain, Low libido, Painful ejaculation, Painful to urinate, Prostate pain, Penis pain, Testicle pain, Vitality low, Other (please explain)
Do you get up at night to urinate? If so, how often?
Does your prostate region ever hurt? If so, is the pain, dull, constant, throbbing or sharp?
Is it ever painful to urinate? If so, describe the pain
Does the urge to urinate interfere with your daily activities?
Do you have any health concerns about your sexuality or vitality?
FEMALE Pregnancy Are you pregnant? If so, how many months?
Are you trying to become pregnant? If so, how long have you been trying?
Number of pregnancies:
Number of births:
Premature births:
Miscarriages:
Abortion:
Have you been diagnosed with any of the following conditions? If so, please select If 'Other', please explain
Please comment on the list in the description box as to how often, sometimes or never you have these symptoms/conditions
Breast pain, Breast discharge, Breast lumps, Miscarriage, Painful intercourse, Vaginal discharge, Vaginal dryness, Vaginal infection, Other
Menstrual cycle Please comment on the list in the description box as to how often, sometimes or never you have these symptoms/conditions
Acne, Bleeding between cycles, Bloating (hands, stomach), Bloating (feet, hands, ankles), Irregular cycle, Mid cycle discomfort, bloating, pressure, Mood swings, Painful menses.
For PMS, please explain any associated symptoms that apply: Mood changes, Nervous tension, Anxiety, Insomnia, Crying/Sadness, Food cravings, Crave sugar/carbs, Irritable if hungry, Fatigue, Abdominal bloating, Weight gain, Breast fullness, Swollen hands/feet, Period pain, Breast pain, Aches & pain, Tiredness, Mental fatigue, Hot flushes, Headaches/Migraine, Other symptoms
Age of first menses:
Length of cycle in days :
Duration of menses in days :
Menstrual blood If 'Other,' please explain
Are you currently in pre, peri or post menopause?
Age when menopause began?
Menopause symptoms If 'Other' selected, please explain
Contraception method If Birth Control Pills, please explain type used
If 'Other' selected, please explain
Environmental Health Is your home damp or mouldy? Do you have specialized air filtration at home? Do you live/work in the city? Do you work in an office building? Are you exposed to toxic materials? Do you smoke or are you exposed to second hand smoke? What do you use as drinking water?
For example, tap, bottled, filtered, reverse, osmosis, spring
Untitled Do you filter your showers? Do you live: How long is your commute?
How do you commute?
For example, by car, public transit, bicycle, walking
Do you spend time in nature? Dental History Date of last dental visit and purpose of visit:
Please explain if you have ever had root canals, cavities, gum disease and number of occurance for each
If there is anything else you would like to add at this time please do so below.
