History Form

Health History & Information Form

NOTE INSTRUCTIONS: PLEASE TYPE IN YOUR INFORMATION AND PRINT IT OUT FOR FAXING TO AVOID DELAYS FROM IN-ABILITY TO READ ILLEGIBLE COPY. THANK YOU.

NameDate Of Birth: Today's Date: Address:City:State:Zip
E-Mail: Confirm E-Mail: Phone:Education Level Completed:Status: S M D W Height:Weight:Occupation: BLOOD TYPE (circLe) A+,A- / B+,B- / AB-, AB+ / O+,O-


HOW DID YOU FIND US? REFERRED BY:

ARE YOU CURRENTLY UNDER A PHYSICIAN'S CARE? WHO, WHERE AND WHAT DIAGNOSIS? WHAT TREATMENTS HAVE BEEN DONE TO DATE ?

IN YOUR OWN WORDS, WHY ARE YOU SEEKING OUR SERVICES ? WHAT ARE THE PRIMARY THINGS YOU WANT ADDRESSED?

DIAGNOSTIC HISTORY: AS FAR BACK AS YOU CAN REMEMBER; CHECK ANY THAT HAVE EVER APPLIED TO YOU AND ESTIMATE DATE SINCE YOU FIRST EXPERIENCED IT; WRITE THE SPECIFICS NEXT TO IT.

ADDICTION / COMPULSIONS (Smoking, Alcohol, Street or Prescription Drugs, Gambling, Shopping, Food, Eating Disorders, etc.); SINCE:DETAILS
ALLERGIES (Environmental, Food, Drugs, etc.); SINCE: DETAILS
ANEMIA; SINCE:DETAILS
ANGINA; SINCE:DETAILS; ANOREXIA / BULIMIA; SINCE:DETAILS
ARTERIOSCLEROSIS; SINCE:DETAILS
ARTHRITIS; SINCE:DETAILS
ASTHMA; SINCE:DETAILS
BACK PAIN; SINCE:DETAILS; BLADDER (infections, cystitis, fallen, etc.); SINCE:DETAILS
BLOOD DISORDER; SINCE:DETAILS
BLOOD IN STOOLS; SINCE:DETAILS
BOWEL TROUBLE (Hemorrhoids, Inflammatory bowel (IBS), Crones', Colitis, etc.); SINCE:DETAILS
BREATHING DIFFICULTY (PULMONARY SYNDROMES LIKE CYSTIC FIBROSIS, ETC.); SINCE:DETAILS
BRONCHITIS (CHRONIC); SINCE:DETAILS
BRUISING EASILY (capillary fragility); SINCE:DETAILS
CANCER / FIBROIDS; SINCE:DETAILS; CARDIOVASCULAR / PERIPHERAL VASCULAR DISEASE; SINCE:DETAILS; CERVICAL DYSPLASIA; SINCE:DETAILS; CHRONIC FATIGUE SYNDROME / CME (CHRONIC MYEOLITIC ENCEPHALITIS); SINCE:DETAILS
COLD HANDS/ FEET; SINCE:DETAILS
CIRCULATORY IMPAIRMENT; SINCE:DETAILS
COLDS, RESPIRATORY INFECTIONS (FREQUENTLY); SINCE:DETAILS
CONSTIPATION (BOWEL MOVEMENTS LESS THAN 2X/ DAY); SINCE:DETAILS; COORDINATION CHANGES; SINCE:DETAILS; CYSTITIS (CHRONIC BLADDER INFECTS W/SCARRING); SINCE:DETAILS
DECREASED APPETITE; SINCE:DETAILS
DECREASED LIBIDO (sex drive); SINCE:DETAILS
DEPRESSION; SINCE:DETAILS
DENTAL WORK (fill out in more detail below); SINCE:DETAILS; DIABETES -- Mellitis Type (I) or Type II (adult onset / Syndrome X); SINCE:DETAILS
DIGESTIVE PROBLEMS; SINCE:DETAILS
DRIBBLING URINE; SINCE:DETAILS
DRY SKIN/ ECZEMA / DERMATITIS; SINCE:DETAILS
EAR TROUBLE; SINCE:DETAILS; EDEMA (tissue swelling such fingers, face, ankles, etc.); SINCE:DETAILS
EMOTIONAL or MOOD SWINGS; SINCE:DETAILS; ENLARGED LYMPH NODES; SINCE:DETAILS
EXCESSIVE SLEEP
SINCE:DETAILS
EMPHYSEMA; SINCE:DETAILS
EYE TROUBLE (vision); SINCE:DETAILS
FATIGUE (does it resolve w/rest?); SINCE:DETAILS; FIBROMYALGIA SYNDROME (Muscle pain with official differential diagnosis); SINCE:DETAILS
FOOT PROBLEMS; SINCE:DETAILS
FREQUENT URINATION; SINCE:DETAILS
FEVERS; SINCE:DETAILS
GALLBLADDER; SINCE:DETAILS
GOUT; SINCE:DETAILS
HEADACHES; SINCE:DETAILS
HEART TROUBLE (includes arrhythmias, palpations, valve prolapse, congestive failure,etc.); SINCE:DETAILS
HEARING TROUBLE; SINCE:DETAILS
HEMORRHOIDS; SINCE:DETAILS
HORMONE IMBALANCE (includes male, female, growth, insulin, growth, etc.); SINCE:DETAILS
HOT FLASHES; SINCE:DETAILS; HYPOGLYCEMIA (Low Blood Sugar); SINCE:DETAILS
HAIR LOSS; SINCE:DETAILS; HAIR GROWTH (EXCESS FACIAL HAIR, ETC.); SINCE:DETAILS; INFECTIONS; SINCE:DETAILS; INCONTINENCE (URINARY); SINCE:DETAILS
INSOMNIA; SINCE:DETAILS
IMMUNE DYSFUNCTION / LOW or AUTOIMMUNE; SINCE:DETAILS
INTESTINAL DISTRESS; SINCE:DETAILS
IRRITABILITY; SINCE:DETAILS
JOINT PAIN; SINCE:DETAILS
JOINT SWELLING; SINCE:DETAILS
KIDNEYS; SINCE:DETAILS
LIVER TROUBLE; SINCE:DETAILS; LOW BLOOD SUGAR / HYPOGLYCEMIA; SINCE:DETAILS
LUNG / PULMONARY TROUBLE; SINCE:DETAILS; LYMPHATIC CONGESTION/ SWELLING / PAIN; SINCE:DETAILS
MEMORY TROUBLE (describe onset of changes, short term, long term, etc.); SINCE:DETAILS
MENSTRUAL CYCLE IRREGULARITIES / CHANGES; SINCE:DETAILS
MENTAL / EMOTIONAL DISTRESS; SINCE:DETAILS; MIGRAINE HEADACHES; SINCE:DETAILS; MUSCLE PAIN / WEAKNESS; SINCE:DETAILS
NERVE PAIN; SINCE:DETAILS
NUMBNESS / NEUROPATHY; SINCE:DETAILS; NIGHT SWEATS; SINCE:DETAILS; PROSTATE ENLARGEMENT (BPH); SINCE:DETAILS
RHEUMATISM; SINCE:DETAILS
RASHES; SINCE:DETAILS
SCLERODERMA; SINCE:DETAILS
SKIN CONDITION; SINCE:DETAILS
STROKE(S) / TIA (transient ischemic attacks); SINCE:DETAILS
SHORTNESS OF BREATH; SINCE:DETAILS
TREMORS (UNCONTROLLED SHAKEY HANDS, LEGS, etc.); SINCE:DETAILS
TMJ (jaw joint pain); SINCE:DETAILS
THYROID; SINCE:DETAILS
WEAK/ LETHARGIC (muscles don't recover; on-going chronic lethargy); SINCE:DETAILS
WEIGHT GAIN; SINCE:DETAILS
WEIGHT LOSS; SINCE:DETAILS
OTHER______________________; SINCE:DETAILS


SURGERICAL HISTORY: i.e. C-sections, Cosmetic procedures, Appendectomy, Hysterectomy, Tonsillectomy, Dental surgeries, Prosthesis, Implants, etc.
Date:Surgery / Scar: Doctor/Hospital Where Performed
Date:Surgery / Scar: Doctor/Hospital Where Performed
Date:Surgery / Scar: Doctor/Hospital Where Performed
Date:Surgery / Scar: Doctor/Hospital Where Performed


INFECTIOUS DISEASE HISTORY: Check Only Applicable Infections
INFECTION TYPE WHEN DETAILS / TREATMENT Candida Yeast Chicken Pox Coxackie Virus Clamydia Cytomegalovirus Virus (CMV) Diphtheria Encephalitis Epstein Barr Virus (mono) Fungal Infections German Measles (Rubella) Gonorrhea Haunta Virus Herpes Virus I,II,Simplex Hepatitis A,B,C,E,G HHV6,7,8 (Roseola) HIV 1-17 Human Papilloma (HPV) Virus Influenza Leishmoniasis Legionairres Lymes (spirochete) Malaria (babesia) Measles (Roseola, HHV6,7) Meningitis Mycoplasma (any) Parasites (worms, amoeba, etc.) Pleurisy Pneumonia Rheumatic Fever Scarlet Fever / scarlentina Shingles Small Pox Swine Flu Syphilis Toxoplasmosis Tuberculosis Typhus OTHER __________________



TRAUMA HISTORY: Injuries (Accidents, Broken bones, Lacerations, Head traumas, etc.). Intense Emotional Stress: : family member long term care giving in illness, death, loss of job, law suits, violence or sexual abuse, divorces, business failure; abduction, robbery, etc.)
Date:Event: Method of Handling (therapy, morning, reconciliation, etc.)

Date:Event: Method of Handling (therapy, morning, reconciliation, etc.)

Date:Event: Method of Handling (therapy, morning, reconciliation, etc.)



DENTAL HISTORY List any type of work including fillings, root canals, bridges, pullings, abscesses, etc.: Date:Work:
Date:Work:; Date:Work:; Date:Work:; Date:Work:; Date:Work:; Date:Work:


VACCINATION HISTORY: ( Include vaccines for overseas travel, flu, military, etc.) includes tetanus, MMR, Flu shots, Typhus, Hep B, etc.: Date:Description:; Date:Description:; Date:Description:; Date:Description:; Date:Description:; Date:Description:; Date:Description:; Date:Description:


TRAVEL HISTORY (Include location, date & how long you stayed): Date:Description:
Date:Description:; Date:Description:; Date:Description:; Date:Description:; Date:Description:; Date:Description:


FAMILY HISTORY (Blood-related siblings, grandparents, aunts, uncles, etc. If Deceased, cause? )
MATERNAL

PATERNAL



ENVIRONMENTAL ISSUES: Have you ever worked with Chemicals (hair salon, paint , refinishing furniture, mining, auto repair, construction, dental assistants, etc.? Do you live near a Toxic Waste Site? Power Plant, Sewage Plant or Nuclear Plant or Research Labratory? Have you ever smelled or seen mold s growing in damp areas around your home or business such as in basements or air conditioning ducts ? )

WHAT TYPE OF WATER DO YOU USE? (be sure to figure water you cook with like for making coffee, etc. as well as shower or bathe with)
Reverse OsmosisDistilledTap WaterFiltered Tap (Britta, etc.)Bottled Spring Well Water

PETS & LIVESTOCK ? DO YOU LIVE OR WORK IN AGRICULTURE ? (list cats, dogs, horses, chickens, ducks, geese, cattle, birds, rodents, turtles, etc.--Either your own or other people's whom you watch. Do you use a kennel ? Do you have any rodent infestations such as rats, mice, etc?)


E.M.F. EXPOSURE Cellular Phones, Wireless Phones, Wireless Devices (hand-helds), Laptops, Desktop computer, High Risk Work-related exposures...electronic & computer technicians, carpenters, pilots, microwave engineers, etc. Electronic Equipment at the workplace such as used in Manufacturing Plants, Nuclear Medicine, Dental Industry, Airline Industry, etc. . . .




SUPPLEMENTS & RX MEDICATIONS: Include Over the Counter Things also. What you take, Why you take them, How you take them.




ALLERGIES / Immune Reactions (List foods, pet, environmental, chemical, drug, supplements, etc.)




ARE YOU NOW OR HAVE EVER BEEN A SMOKER ? (this includes marajuana, cigarettes, or chewing tobacco) YESNO
DETAILS:


WOMEN ONLY:
DATES OF LAST MENSTRUAL CYCLE # DAYS
ARE YOU MENOPAUSAL? YESNO
IF YOU'RE MENOPAUSAL, DID YOU HAVE A HYSTERECTOMY OR PARTIAL? YESNO
DESCRIBE:
HAVE YOU EVER HAD FIBROIDS OR FIBROCYSTIC BREASTS OR OVARIES YESNO
DETAILS:
ARE YOU NOW OR HAVE YOU EVER USED BIRTH CONTROL PILLS? YESNO
IF YES, HOW LONG, TYPE, ETC.?
HAVE YOU EVER HAD AN EARLY TERMINATED PREGNANCY ? YESNO
YOUR AGE AT THE TIME:HOW MANY WEEKS (Gestation) ?
ANY PROCEDURES DONE OR COMPLICATIONS ?
DESCRIBE HOW YOU RECOVERED:
HAVE YOU EVER EVALUATED FOR AN STD ? (herpes, HPV, clamydia, etc.) YESNO
DESCRIBE TREATMENT:

PERSONAL / SOCIAL HISTORY (This is completely confidential...just so I can get to know you better ...)

CURRENT OCCUPATION:SINCE
MARRIED? YES NO IF YES, HOW LONG?
IS THE RELATIONSHIP SUPPORTIVE & HEALTHY?
IF DIVORCED, HOW LONG? AMICABLE ?
CHILDREN? YESNO AGES:
CHILDREN LIVE PRIMARILY WITH?
UNMARRIED PARTNERS YESNO FOR HOW LONG?
IS THE RELATIONSHIP SUPPORTIVE & HEALTHY?
HOMOSEXUAL OR BISEXUAL RELATIONSHIPS?HOW LONG?
ANY SPIRITUAL AFFILIATION OR FAITH? YESNO DETAILS:
DO YOU CONSIDER YOURSELF ACTIVELY PRACTICING? YESNO

ADDITIONAL PERSONAL INFORMATION YOU FEEL WE NEED THAT WOULD BE HELPFUL TO HELP US GET TO KNOW YOU: (HOBBY'S, MUSICAL INTERESTS, PASSIONS IN LIFE, ETC.)

PHYSICAL ACTIVITY LEVEL ON A WEEKLY BASIS: (please check what is your normal weekly level, not your best)

1. NOT SO MUCH: DISABLED OR TOO ILL / DISLIKE / DON'T TAKE TIME 2. INFREQUWENTLY ... COUCH or COMPUTER POTATO / OFFICE COMMUTER. LIGHT YARD WORK OR WALKS OCCASSIONALLY. 3. INTERMITTENT: BREAK A SWEAT FOR 30+ MINUTES, INTERMITTENTLY THROUGHOUT THE MONTH (Yardwork, Hikes, etc.) 4. WEEKY: AEROBICS, WEIGHTS, HOME GYM, RACKETBALL, TENNIS, etc. 45+ MIN. AT LEAST 3 TIMES WEEKLY 5. REGULARLY INTENSIVE: CONSTRUCTION, SPORTS, RUNNERS, HIKERS, DANCER, BIKER, OR WORKOUTS 1+ HR. 5 X WEEK OR MORE

DO YOU SWEAT WHEN HOT OR WITH EXERTION ? YESNO
IF NO, DESCRIBE DETAILS:

DIET & NUTRITION : TELL ME WHAT YOU EAT , HOW OFTEN, AND HOW MUCH, USUALLY IN A GIVEN WEEK OR DAY. BE SURE TO INCLUDE SNACKS, COFFEE, TEA, ETC. PLEASE BE SURE TO INCLUDE THINGS LIKE SODAS, STARBUCKS, ETC.







(909) 338-3533 / FAX (909) 338-3743
E-mail: dbormann@arrowheadhealthworks.com *ARROWHEADHEALTHWORKS.COM

INFECTION TYPE	WHEN	DETAILS / TREATMENT
Candida Yeast
Chicken Pox
Coxackie Virus
Clamydia
Cytomegalovirus Virus (CMV)
Diphtheria
Encephalitis
Epstein Barr Virus (mono)
Fungal Infections
German Measles (Rubella)
Gonorrhea
Haunta Virus
Herpes Virus I,II,Simplex
Hepatitis A,B,C,E,G
HHV6,7,8 (Roseola)
HIV 1-17
Human Papilloma (HPV) Virus
Influenza
Leishmoniasis
Legionairres
Lymes (spirochete)
Malaria (babesia)
Measles (Roseola, HHV6,7)
Meningitis
Mycoplasma (any)
Parasites (worms, amoeba, etc.)
Pleurisy
Pneumonia
Rheumatic Fever
Scarlet Fever / scarlentina
Shingles
Small Pox
Swine Flu
Syphilis
Toxoplasmosis
Tuberculosis
Typhus
OTHER __________________