Vreeland - FirstLine Therapy Patient Health History

FirstLine Therapy Patient’s Health History

(Confidential)
Today's date

MonthDayYear
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone

Area CodePhone Number
Occupation
Age
Height
Sex

MaleFemale
Marital status (optional)

SingleMarriedPartneredSeparatedDivorcedWidowed
Are you recovering from a cold or flu?

YesNo
Are you pregnant?

YesNo
Reason for your visit
List current health problems for which you are being treated:
What types of therapies have you tried for these problems(s) or to improve your health overall?

Diet modificationFastingVitamins / mineralsHerbsHomeopathyChiropracticAcupunctureConventional drugsOther
Do you experience any of these general symptoms on a regular basis?

Debilitating fatigueDepressionDisinterest in sexDisinterest in eatingShortness of breathPanic attacksHeadachesDizzinessInsomniaNauseaVomitingDiarrheaConstipationFecal incontinenceUrinary incontinenceLow grade feverChronic pain/inflammationBleedingDischargeItching/rash
Current medications (prescription or over-the-counter)
Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis):
Outcome
Major hospitalization, surgeries, injuries. Please list all procedures, complicatons (if any) and dates:
Indicate the level of stress you are experiencing on a scale of 1 to 10
Identify the major causes of stress (e.g., changes in job, residence or finances)
Do you consider yourself:

UnderweightOverweightHealthy weight
Your weight today
Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months?

YesNo
Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) and/or life-threatening activities (e.g., firefighter, police officer, etc.)?
What are your current health goals?
Medical History

ArthritisAllergies/hay feverAsthmaAlcoholismAlzheimer’s diseaseAutoimmune diseaseBlood pressure problemsBronchitisCancerChronic fatigue syndromeCarpal tunnel syndromeCholesterol, elevatedCirculatory problemsColitisDental problemsDepressionDiabetesDiverticular diseaseDrug addictionEating disorderEpilepsyEmphysemaEyes, ears, nose, throat problemsEnvironmental sensitivitiesFibromyalgiaFood intoleranceGastroesophageal reflux disease
Genetic disorderGlaucomaGoutHeart diseaseInfection, chronicInflammatory bowel diseaseIrritable bowel diseaseKidney or bladder diseaseLearning disabilitiesLiver or gallbladder disease (stones)Mental illnessMental retardationMigraine headachesNeurological problemsSinus problemsStrokeThyroid troubleObesityOsteoporosisPneumoniaSexually transmitted diseaseSeasonal affective disorderSkin problemsTuberculosisUlcerUrinary tract infectionVaricose veinsOther
Medical – Men

Benign prostatic hyperplasiaProstate cancerDecreased sex drive
InfertilitySexually transmitted diseaseOther
Medical – Women

Menstrual irregularitiesEndometriosisInfertilityFibrocystic breastsFibroids/ovarian cystsPremenstrual syndrome (PMS)Breast cancer
Pelvic inflammatory diseaseVaginal infectionsDecreased sex driveSexually transmitted diseaseSurgical menopauseMenopauseOther
Date of last GYN exam
Mammogram

+—
PAP

+—
Form of birth control
Number of children
Number of pregnancies
C-sections
Age of first period
Date of last menstrual cycle
Length of cycle
Interval of time between cycles
Any recent changes in normal menstrual flow (e.g., heavier, large clots, scanty)
Family Health History (Parents and Siblings)

ArthritisAsthmaAlcoholismAlzheimer’s diseaseCancerDepressionDiabetesDrug addictionEating disorderGenetic disorderGlaucomaHeart diseaseInfertilityLearning disabilitiesMental illnessMental retardationMigraine headachesNeurological disorders (Parkinson’s, paralysis)ObesityOsteoporosisStrokeSuicideOther
Health Habits
Cigarettes
Cigars
Wine
Liquor
Beer
Coffee
Tea
Soda with caffeine
Other sources of caffeine
Water consumption
Exercise
Amount you exercise
Duration of workouts
Walking
Run, jog, other aerobics
Weight lift
Stretch
Other
Nutrition and Diet

Mixed (meat & veg.)VegetarianVeganSalt restrictionFat restrictionStarch/carbohydrate restrictionThe Zone DietTotal calorie restriction
Food specific restrictions

dairywheateggssoycornall glutenOther
Eating Habits

One meal/dayTwo meals/dayThree meals/day
Graze (small frequent meals)Generally eat on the runEat constantly whether hungry or not
Skip meals
Food Frequency
Fruits
Dark green or deep yellow/orange vegetables
Grains (unprocessed)
Beans, peas, legumes
Dairy, eggs
Meat, poultry, fish
Current Supplements

Multivitamin/mineralVitamin CVitamin EEPA/DHAEvening primrose/GLACalciumMagnesiumZincFriendly flora (acidophilus)Digestive enzymesAmino acidsCoQ10Antioxidants (lutein, resveratrol)HerbsHomeopathyProtein shakesSuperfoods (bee pollen, phytonutrients)Liquid mealsOther
Minerals - describe
I Would Like:
Energy, Vitality

Feel more vitalHave more energyHave more enduranceBe less tired after lunchSleep betterBe free of painGet less colds and fluGet rid of allergiesNot be dependent on over-the-counter medications like aspirin, sleeping aids, etc.Stop using laxatives and stool softenersImprove sex driveOther
Body Composition

Lose weightBurn more body fatBe strongerHave better muscle toneBe more flexibleOther
Stress: Mental & Emotional

Learn how to reduce stressThink more clearlyBe more focusedImprove memoryBe less depressedBe less moodyBe less indecisiveFeel more motivatedOther
Life Enrichment

Reduce my risk of degenerative diseaseSlow down accelerated agingMaintain a healthier life longerChange from a “treating-illness” orientation to creating a wellness lifestyleOther
Should be Empty:

FirstLine Therapy Patient’s Health History