DR.CRISTINA COLOMA, ND 2888 GARDNER COURT ABBOTSFORD, BC V2T 5H9 Phone/Fax (604)
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1 DR.CRISTINA COLOMA, ND 2888 GARDNER COURT ABBOTSFORD, BC V2T 5H9 Phone/Fax (604) Name: Date: Address: City: Province/State: Zip/Postal Code: Telephone # (home): (cell): address: Age: Date of Birth: Gender: female male Level of Education: Married: Separated: Divorced: Widowed: Single:_ Partnership:_ Live with: Spouse Partner Parents Children Friends Alone Occupation: Hours per week: Retired: CareCard#: Work phone: How did you hear about our clinic? Next of Kin or other to reach in an emergency: Relationship: Address: Phone: What are your most important health problems? List as many as you can in order of importance: 1) 2) 3) 4) 5) 6) 1
2 PLEASE FILL OUT BOTH SIDES OF EACH PAGE CONTEXT OF CARE REVIEW Successful health care and preventive medicine are only possible when the physician has a complete understanding of the patient physically, mentally and emotionally. The nature of your responses to the following questions will go along way in assisting my understanding of your truest desires. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to assist your health needs. 1) Why did you choose to come to this clinic? 2) What do you love to do? 3) What health outcome(s) do you want from this visit to our clinic?? 4) How do you see yourself 3 months from now? 5) How do you see yourself 6 months from now? 6) How do you see yourself one year from now? 7) What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Rate from 0 to 10, with 10 being 100% committed) 0% % 8) What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? (please list) 9) What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive lifestyle habits: (please list) 10) What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and in adhering to the therapeutic protocols which we will be sharing with you? 11) Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making? 2
3 Family History Do you have a family history of any of the following (please circle)? Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Epilepsy Arthritis Glaucoma Tuberculosis Stroke Anemia Mental Illness Asthma/Hayfever/Hives Any other relevant family history? What is your heritage: German Nordic Celtic Other Childhood Illnesses Please circle whether you had any of these as a child: Scarlet fever Diphtheria Rheumatic fever Mumps Measles German measles Hospitalization, Surgery, Imaging What hospitalizations, surgeries, X-Rays, CAT Scans, EEG, EKG s have you had? year: year: year: year: year: year: Are you hypersensitive or allergic to... Any drugs? Any foods? Any environmentals or chemicals? Allergies Current Medications Do you take or use? Laxatives Y N Pain relievers Y N Antacids Y N Cortisone Y N Appetite suppressants Y N Antibiotics Y N Tranquilizers Y N Thyroid medication Y N Sleeping pills Y N Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking? 1) 5) 2) 6) 3) 7) 4) 8) General Height: Weight: lbs. Weight 1 year ago: lbs. Maximum Weight : When: When during the day is your energy the best? worst? 3
4 Breakfast: Lunch: Dinner: Snacks: To drink: Typical Food Intake FOR THE FOLLOWING, PLEASE CIRCLE Habits Main interests and hobbies? Do you exercise? Y N If yes, what kind? How often? Average 6-8 hrs. sleep? Y N Enjoy your work? Y N Sleep well? Y N Take vacations? Y N Awaken rested? Y N Spend time outside? Y N Have a supportive relationship? Y N Watch television? Y N Have a history of abuse? Y N how many hours? Any major traumas? Y N P Read? Y N Use recreational drugs? Y N P how many hours? Been treated for drug dependence? Y N P Use alcoholic beverages? Y N P Do you eat 3 meals a day? Y N Treated for alcoholism? Y N P Do you go on diets often? Y N Do you use tobacco? Y N P Do you eat out often? Y N Smoked previously? Y N P Do you drink coffee? Y N P How many years? Drink black/green tea? Y N P How many packs per day? Do you drink cola/other sodas? Y N P Do you eat refined sugar? Y N P Do you add salt? Y N P Do you have a religious or spiritual practice? If yes, what? REVIEW OF SYSTEMS Mental / Emotional Treated for emotional problems? Y N P Depression? Y N P Mood Swings? Y N P Anxiety or nervousness? Y N P Considered/Attempted suicide? Y N P Tension? Y N P Poor concentration? Y N P Memory problems? Y N P Difficulty completing projects? Y N P Easily Distracted? Y N P Confusion? Y N P Poor/Short Attention Span? Y N P Immune Reactions to immunizations? Y N P Reactions to vaccinations? Y N P Chronic Fatigue Syndrome? Y N P Chronic infections? Y N P Chronically swollen glands? Y N P Slow wound healing? Y N P 4
5 Endocrine Hypothyroid? Y N P Heat or cold intolerance? Y N P Hypoglycemia? Y N P Diabetes? Y N P Excessive thirst? Y N P Excessive hunger? Y N P Fatigue? Y N P Seasonal depression? Y N P Neurologic Seizures? Y N P Paralysis? Y N P Muscle weakness? Y N P Numbness or tingling? Y N P Loss of memory? Y N P Easily stressed? Y N P Vertigo or dizziness? Y N P Loss of balance? Y N P Skin Rashes? Y N P Eczema, Hives? Y N P Acne, Boils? Y N P Itching? Y N P Color Change? Y N P Perpetual Hair Loss? Y N P Lumps? Y N P Night Sweats? Y N P Head Headaches? Y N P Head Injury? Y N P Migraines? Y N P Jaw/TMJ problems Y N P Eyes Spots in Eyes? Y N P Cataracts? Y N P Impaired vision? Y N P Glasses or contacts? Y N P Blurriness? Y N P Eye pain/strain? Y N P Color blindness? Y N P Tearing or dryness? Y N P Double Vision? Y N P Glaucoma? Y N P Ears Impaired hearing? Y N P Ringing? Y N P Earaches? Y N P Dizziness? Y N P Nose and Sinuses Frequent colds? Y N P Nose Bleeds? Y N P Stuffiness? Y N P Hayfever? Y N P Sinus problems? Y N P Loss of smell? Y N P Mouth and Throat Frequent sore throat? Y N P Copious saliva? Y N P Teeth grinding? Y N P Sore tongue/lips? Y N P Gum problems? Y N P Hoarseness? Y N P Dental cavities? Y N P Jaw clicks? Y N P Neck Lumps? Y N P Swollen glands? Y N P Goiter? Y N P Pain or stiffness? Y N P 5
6 Respiratory Cough? Y N P Sputum? Y N P Spitting up blood? Y N P Wheezing Y N P Excessive Phlegm? Color? Y N P Itching in Chest? Y N P Asthma? Y N P Bronchitis? Y N P Pneumonia? Y N P Pleurisy? Y N P Emphysema? Y N P Difficulty breathing? Y N P Pain on breathing? Y N P Shortness of breath? Y N P Shortness of breath at night? Y N P lying down? Y N P Tuberculosis? Y N P Tight Chest? Y N P Cardiovascular Heart disease? Y N P Angina? Y N P High/Low Blood Pressure? Y N P Murmurs? Y N P Blood clots? Y N P Fainting? Y N P Phlebitis? Y N P Palpitations/Fluttering? Y N P Rheumatic Fever? Y N P Chest pain? Y N P Swelling in ankles? Y N P Gastrointestinal Trouble swallowing? Y N P Acid Reflux / Heartburn? Y N P Change in thirst? Y N P Abdominal pain or cramps? Y N P Change in appetite? Y N P Belching or passing gas? Y N P Nausea/vomiting Y N P Constipation? Y N P Ulcer? Y N P Diarrhea? Y N P Jaundice (yellow skin)? Y N P Bowel Movements: How often? Gall Bladder disease? Y N P Is this a change? Liver Disease? Y N P Black stools? Y N P Hemorrhoids? Y N P Blood in stool? Y N P Urinary Pain on urination? Y N P Increased frequency? Y N P Frequency at night? Y N P Inability to hold urine? Y N P Bedwetting? Y N P Incomplete urination? Y N P Frequent infections? Y N P Kidney stones? Y N P Musculoskeletal Joint pain or stiffness? Y N P Arthritis? Y N P Broken bones? Y N P Weakness? Y N P Muscle spasms or cramps? Y N P Sciatica? Y N P Blood / Peripheral Vascular Easy bleeding or bruising? Y N P Anemia? Y N P Deep leg pain? Y N P Cold hands/feet? Y N P Varicose veins? Y N P Thrombophlebitis? Y N P 6
7 Male Reproduction Hernias? Y N P Testicular masses? Y N P Testicular pain? Y N P Prostate disease? Y N P Venereal disease? Y N P Discharge or sores? Y N P Are you sexually active? Y N Chlamydia? Y N P Sexual orientation: Gonorrhea? Y N P Impotence? Y N P Condyloma? Y N P Premature ejaculation? Y N P Herpes? Y N P Birth control? Type? Syphilis? Y N P Female Reproduction / Breasts Age of first menses? Date of last annual exam/ PAP _ Age of last menses? (if menopausal) Are cycles regular? Y N Length of cycle? days Bleeding between cycles? Y N P Duration of menses? days Pain during intercourse? Y N P Painful menses? Y N P Clotting? Y N P Heavy or excessive flow? Y N P Discharge? Y N P PMS? Y N P Birth control? Y N P If yes, what are your symptoms? What type? Number of pregnancies: Number of live births: Endometriosis? Y N P Number of miscarriages: Ovarian cysts? Y N P Number of abortions: Difficulty conceiving? Y N P Menopausal symptoms? Y N P Cervical Dysplasia? Y N P Abnormal PAP? Y N P Sexual difficulties? Y N P Chlamydia? Y N P Gonorrhea? Y N P Condyloma? Y N P Herpes? Y N P Syphilis? Y N P Are you sexually active? Y N Sexual orientation: Do you do breast self exams? Y N P Breast lumps? Y N P Breast pain/tenderness? Y N P Nipple discharge? Y N P Is there anything else you would like to add or comment on? Thank you for your time and effort. Our team looks forward to providing you with the best possible care. 7 06/14
(PLEASE CIRCLE YES ANSWERS ONLY)
(PLEASE CIRCLE YES ANSWERS ONLY) Childhood Illnesses Scarlet Fever Y N Diphtheria Y N Rheumatic fever Y N Mumps Y N Measles Y N German Measles Y N Hospitalizations and Surgery What hospitalizations or
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