Patient Health Form – Integrative Health and Hormone Clinic

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1731 Boyson Road, Hiawatha, IA 52233
(319) 363-0033

DEMOGRAPHIC PROFILE

Please complete to the best of your knowledge.

Today's Date*

MM slash DD slash YYYY

Name*

First Last

Email*

Phone*

Date of Birth*

MM slash DD slash YYYY

Sex*

Male

Female

Height

Weight

Address*

Street Address Address Line 2 (optional) City State ZIP Code

Are you filling this form out for a minor?*

(someone under the age of 18)

Yes

Legal Guardian

First Last

Relationship to patient

Address

Street Address Address Line 2 City State ZIP Code

Phone

Name of Insurance

Policy Holder's Name

Insurance Policy / Card #

Primary Care Provider

Phone

Fax

Alternative Providers (i.e. Chiropractor)

Phone

Preferred Pharmacy

Phone

Please list your race

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Employment Status

Employed

Not Employed

Retired

Occupation

COMPREHENSIVE HEALTH INFORMATION

Referring Provider (if applicable)

Phone

Fax

How did you hear about us?

(If recommended by a current patient, please state who so we can send them a token of our appreciation!)

History of Present Illness

When listing your history below, please prioritize and score their severity on a scale of 0-10 with 0 being non-bothersome and 10 being the worst imaginable. We may not have time to discuss everything in the first visit so prioritizing will assist us in addressing your most important issues during your initial visit. Please list in this format: Illness | Score | Approximate time it started Use a new line for each illness.

Is there anything that makes these problems better or worse?

Past Medical History

Alzheimer’s

Anemia

Anxiety

Arthritis

Asthma

Back Injury

Bladder tumor

Bleeding problems

BPH

Bronchitis

Cancer

Cataracts

Celiac

Chest Pain

Constipation

COPD

Cysts (ovarian)

Depression

Diabetes

Diverticulitis

Dysmenorrhea

Endometriosis

Falls

Fertility problems

Fibroids

Fractures

Glaucoma

Headaches

Head Injury

Heart attack

Heart disease

Hemorrhoid

HIV/AIDS

Hypertension

Thyroid Disease

Incontinence

Irritable bowel

Kidney stones

Liver disease

Mental health

Multiple sclerosis

Osteoporosis

Parkinson’s

PCOS

Pneumonia

Prolapse vaginal

Prostate issues

Pulmonary emboli

Renal disease

Sinusitis

Skin sensitivities

Spinal cord injury

STDs

Stroke

Seizures

Vascular problems

Heart murmur

Urinary Infection

Other

If you checked cancer above, please let us know what type of cancer you had.

Other? Please list:

Past Surgical History

Bladder suspension

C-section

Cataracts

Cardiac related

Hemorrhoids

Hysterectomy

Joint replacement

Ovaries removed

Pacemaker

Polyps

Other

Other? Please list:

Immunization History

Polio

Tetanus

MMR

Pertussis

Diphtheria

Meningitis

Influenza

Gardisil

BCG for TB

Hepatitis B

Pneumonia

I prefer to not be vaccinated

If you selected Tetanus, Influenza, and/or Pneumonia, what year did you receive these vaccinations?

List vaccine and then year.

Enviromental Allergies

Food Allergies

Drug Allergies

Please list an example of what you eat for breakfast

Please list an example of what you eat for lunch

Please list an example of what you eat for dinner

How many ounces of water do you drink daily?

Current Medications

Please list Medication, Dosage, Frequency, and Who prescribed it.

Do you currently have an intrauterine device (IUD)?

Yes

Current Nutritional/Herbal Supplements-Please bring supplements or a copy of the Ingredients to your visit

Please list Supplement, Dosage, Frequency, and Who prescribed it.

Social History

Do you smoke?

History of smoking?

Do you consume caffeine?

Do you exercise?

Do you drink alcohol?

Do you have amalgam, silver, or gold fillings?

Metal dental fillings removed?

Marijuana

Live alone

Other drugs

Married

Employed

Unemployed

Occupational exposures (toxins)

Disabled

How many packs do you smoke per day?

When did you quit smoking?

How many times per day do you consume caffeine?

How many times do you exercise per week?

On average, how many hours do you sleep per night?

How were you delivered as a baby?*

Vaginal Delivery

Cesarean Delivery

Were you breastfed as a child for over 6 months?*

Yes

Have you taken numerous rounds of antibiotics in your life?*

Yes

If you have taken antibiotics, for what and how long?

Have you had past exposure to water damaged buildings containing mold?

Yes

Not Sure

Do you have current exposure to water damaged buildings containing mold?

Yes

How would you rank your stress from 0-10 with 10 ranking the highest?

Do you have history of any significant tick/bug bites?

Yes

Are you interested in IV Nutritional therapy?

Yes

Have you had any of these in the past year?

Vision Check

Dental Visit

Yearly Exams

Pap

Mammogram

In the past 10 years?

Bone Density Scan

Colonoscopy

EKG

Last lab work

Perform breast self-exams

Perform testicular self-exams

What year did you have the Bone Density Scan?

What year did you have the Colonoscopy?

What year did you have the EKG?

What year did you have your last lab work?

REVIEW OF SYSTEMS

Check all that apply.

Constitutional Fevers

Hot flashes

Fevers

Night sweats

Chills

Fatigue

Problems falling asleep

Problems staying asleep

Weight loss

Weight gain

Appetite change

Head/Eyes

Contact lenses

Glasses

Vision loss

Excessive tears

Dry eyes

Irritation

Itching

Blurring

Double vision

Discharge

Light sensitivity

Ears, Nose, Throat

Otalgia-ear pain

Otorrhea-drainage

Hearing loss

Ringing in ears

Nasal polyps

Nose bleed

Sinus tenderness

Congestion

Postnasal drip

Neck stiffness

Hoarseness

Sore throat

Issues swallowing

Dentures

Mouth sores

Bleeding gums

Cardiac

Chest pain

Palpitations

Irregular beat

Murmur

Fainting

History of Rheumatic Fever

Edema (swelling)

Shortness of breath with activity

Vascular

Varicose Veins

Claudication

Raynaud’s

Respiratory

Cough

Cough produces mucous

Wheezing

Shortness of Breath

Wear oxygen

Wear BI/CPAP

Color of mucous?

Amount of mucous?

Gastroinstestinal

Constipation

Hemorrhoids

Diarrhea

Nausea

Vomiting

Changes in bowel pattern

Epigastric pain

Abdominal pain

Blood in stool

Flatulence

Pain right upper

Pain right lower

Pain left upper

Pain left lower

Ulcers

Belching

Food intolerances

Reflux

Hernia

Genitourinary

Hesitancy

Frequency

Urgency

Painful Urination

Blood in Urine

Excessive Urination

Leakage of urine

Number of urinations at night

Musculoskeletal

Back Pain

Joint pain

Joint Swelling

Muscle weakness

Cramping

Muscle Stiffness

Muscle Pain

Gout

Limited ROM

Dermatology

Acne

Birthmarks

Rashes

Itching

Dryness

Scars

Ulcers

Suspicious lesions

Mole Changes

Neurological

Headache

Dizziness

Lightheadedness

Weakness

Head Spinning

Nerve Pain

Seizures

Tremor

Memory loss

Endocrine

Heat Intolerance

Cold Intolerance

Excessive urination

Hair changes

Nail changes

Goiter

Hematology

Bruise easily

Swollen lymph nodes

Psych: How do you describe your mood?

Pleasant

Depressed

Anxious

Panic easily

PTSD

Pain: If you have pain, what is the location of your pain?

On a scale of 0-10 with 10 being the worst pain imaginable and 0 being no pain, rank your pain.

What is the frequency of your pain?

No pain

Sometimes

50% of the time

Frequently

Constant

Female

Breast lumps

Breast tenderness

Nipple discharge

Decreased libido

Vaginal dryness

Vaginal discharge

Vaginal bleeding

Vaginal sores

Painful cycles

Pelvic pain

Abnormal PAP

Abnormal mammogram

Pregnancy

Miscarriage

On birth control

STD's

PMS symptoms in second half of cycle

Number of pregnancies?

Number of miscarriages?

If currently taking birth control, which kind and how long have you been on it?

Have you had a hysterectomy?

Yes

Were your ovaries removed?

Have you taken hormone replacement therapy (HRT)?

Yes

Which kind?

Please check the routes that you have taken of HRT

Oral pills

Patch

Gel/cream

Sublingual troche

Vaginal ring

Your age when you began menopause?

Year you began menopause?

Are you interested in BioTe hormone pellet therapy?

Yes

Unsure

Any other information we should know?

Male

Testicular mass

Testicular pain

Erectile dysfunction

Decreased libido

Penile sores

Change in urine stream

Prostate problems

STD's

Penile discharge

Are you interested in BioTe hormone pellet therapy?

Yes

Unsure

Any other information we should know?

FAMILY MEDICAL HISTORY

List any family relations that have had a history of the diseases below. For example, if your grandmother on your mother’s side had diabetes, find diabetes in the list below, then click on "Choose One" and then select “Maternal Grandmother”.

Alzheimer’s

Anemia

Asthma

Osteoarthritis

Celiac Disease

Depression

Diabetes

Epilepsy

Glaucoma

Heart Disease

High Blood Pressure

Infertility

Liver Disease

Mental Illness

Osteoporosis

Stroke

Tuberculosis

Autoimmune Disease

Hypothyroid

Multiple Sclerosis

Psoriasis

Rheumatoid Arthritis

Cancer

Breast Cancer

Colon Cancer

Ovarian Cancer

Prostate Cancer

PCOS (Polycystic Ovary Syndrome)

Check this box if you have double checked that all relevant information has been completed and you are ready to submit the form.*

Yes, I have completed all the relevant information.

CALL (319) 363-0033

CONTACT

DEMOGRAPHIC PROFILE

COMPREHENSIVE HEALTH INFORMATION

REVIEW OF SYSTEMS

FAMILY MEDICAL HISTORY