Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ
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1 Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ Female Health History Patient Name: Date: DOB: Age: Street Address: City: State: Zip: Home phone: Work Phone: Cell Phone: Highest level of education: Occupation: Employer Hours work per week: Marital Status (circle): Single Married Partner Separated Divorced Widowed Insurance Company: Policy: Group #: Name of Insured Relation to Insured Person to call in case of Emergency: Relationship to you: Phone number for emergency contact: Previous/Current Physician and City: How did you hear of the clinic? Chief Complaints What are your main health concerns/reasons for your visit (Please list in Order of Importance) 1. Date First Noticed or Diagnosed: 2. Date First Noticed or Diagnosed: 3. Date First Noticed or Diagnosed: 4. Date First Noticed or Diagnosed: 5. Date First Noticed or Diagnosed: Please list any Additional Questions or Expectations of your visit today: List All Surgeries and Hospitalizations: 1. Date: 2. Date: 3. Date: 4. Date: 5. Date:
2 List All Accidents, Injuries, Physical Traumas: 1. Date: 2. Date: 3. Date: Please Note When and Why You Had Each of The Following: X- rays: MRI/Cat Scans: Ultrasounds: Accidents: Last time you had blood work done and with what doctor: Please List All Sensitivities/Allergies/Reactions Drugs: Foods: Environment: Did you have the following Disease (D), Get Immunized for it (I), or Neither (N): Measles: D I N Diptheria: D I N Mumps: D I N Tetanus: D I N Rubella: D I N Whooping Cough: D I N Chickenpox: D I N Hemophilus (Hib): D I N Hepatitis B: D I N German Measles: D I N Polio: D I N Any vaccination reactions: List Yes, No, or Past regarding use of the following: Antacids: Y N P Steroids: Y Y N P Smoking: Y N P Packs per day if Yes/Past: Analgesics: Y N P Laxatives: Y N P Coffee: Y N P Cups per day if Yes/Past: Soda Pop: Y N P Ounces per day if Yes/Past: Alcohol: Y N P How often and how much if Yes/Past:
3 Any alcohol addiction: Y N P Any alcohol treatment: Y N P Recreational drugs: Y N P Any drugs addiction: Y N P Any drug treatment: Y N P Family history Father Mother Siblings Grandparents Spouse Children Age if living Age when died Reason for death Cancer (type) Y N Y N Y N Y N Y N Y N High Blood Pressure Y N Y N Y N Y N Y N Y N Heart Attack/stroke Y N Y N Y N Y N Y N Y N Heart disease Y N Y N Y N Y N Y N Y N Asthma/allergies Y N Y N Y N Y N Y N Y N Mental illness Y N Y N Y N Y N Y N Y N Addiction Y N Y N Y N Y N Y N Y N TB Y N Y N Y N Y N Y N Y N Auto- immune disease Y N Y N Y N Y N Y N Y N Diabetes Mellitus Y N Y N Y N Y N Y N Y N Osteoporosis Y N Y N Y N Y N Y N Y N Any other conditions: Please give full name, dosage, how often and how long you have taken each medicine/supplement. Pharmaceuticals Dose When/How Often How Long Supplements Dose When/How Often How Long
4 5. 6. Review of Systems: Present Weight: Height: Max Height: Maximum Weight and when: Minimum Weight and when: Weight one year ago: Ideal Weight: REGARDING THE NEXT SECTION: Please Circle Y if you have the problem NOW, N if you ve NEVER had the problem, P if you had the problem in the PAST. The general state of your health is: Excellent Good Average Fair Poor On average describe your energy level from 1 (low)- 10: (high) Good Energy: Y N P Fatigue: Y N P If you have fatigue, when is it the worst: morning, afternoon, evening? If you have fatigue, can you do what you need to during the day? Y N Skin: Rash: Y N P Color Change: Y N P Hives: Y N P Lump: Y N P Psoriasis/eczema: Y N P Itchy: Y N P Dry: Y N P Warts/moles: Y N P Cancer: Y N P Perspiration: Y N P Head: Headache: Y N P Migraine: Y N P Dandruff: Y N P Head Injury: Y N P Oil/dry hair: Y N P Hair loss: Y N P Eyes: Dry/Watery: Y N P Blurry vision: Y N P Double vision: Y N P Cataracts: Y N P Glaucoma: Y N P Styes: Y N P Strain: Y N P Discharge: Y N P Itchy: Y N P Dark under eyelid: Y N P Ears: Infections: Y N P Ear Wax: Y N P Hearing Loss: Y N P Tinnitus: Y N P Nose: Frequent colds: Y N P Nosebleeds: Y N P Congestion: Y N P Post nasal drip: Y N P
5 Polyps: Y N P Seasonal allergies: Y N P Mouth/Throat: Canker sores: Y N P Cold sores: Y N P Sore throat: Y N P Gum disease: Y N P Dentures: Y N P Cavities: Y N P Loss of taste: Y N P Hoarseness: Y N P How often you do you brush your teeth? Floss? How often do you go to the Dentist? Neck: Stiffness: Y N P Swollen glands: Y N P Full movement: Y N P Tension: Y N P Respiratory: Cough: Y N P TB: Y N P Wheezing: Y N P Painful breathing: Y N P Shortness of breath with exertion: Y N P Bronchitis: Y N P Shortness of breath sitting: Y N P Pneumonia: Y N P Shortness of breath lying down: Y N P Asthma: Y N P Cardiovascular: High blood pressure: Y N P Rheumatic Fever: Y N P Low blood pressure: Y N P Murmurs: Y N P Arrhythmias: Y N P Palpitations: Y N P Edema: Y N P Chest pain: Y N P Gastrointestinal: Heartburn: Y N P Bowel movement frequency: Indigestion: Y N P Recent change in BM: Y N P Bloating: Y N P Diarrhea or constipation: Y N P Nausea: Y N P Hemorrhoids: Y N P Vomiting: Y N P Gall bladder disease: Y N P Change in Appetite: Y N P Liver disease: Y N P Pancreatitis: Y N P Ulcer: Y N P List all travel outside the US over the last five years: Have you noticed any of the below in your stool or toilet bowl or on toilet paper? Blood Mucus Undigested Food Black Stool Lighter colored stool How many antibiotics have you had in your entire life? If you are over 50 y/o, when was your last colonoscopy? Urinary Tract: Incontinence: Y N P Pain/burning with urination: Y N P Frequent infections: Y N P Kidney stones: Y N P
6 Urgency: Y N P Discharge/blood: Y N P Female Reproductive: Times Pregnant: Births Miscarriages Abortions Difficulty Getting Pregnant? Do you do a Self Breast exam regularly? Y N How often? Any breast tenderness, lumps, nipple discharge? If Menopausal, at what age did it begin? Any problematic menopausal symptoms? If yes, how were/are they treated? Age periods began: How often periods occur? How long does the period last? Periods: Heavy Bleeding: Y N P Clotting: Y N P Cramping: Y N P Pain: Y N P PMS: Y N P Food Cravings: Y N P Bloating: Y N P Irritability: Y N P Breast tenderness: Y N P Last Pap Smear: Any abnormal paps? Y N P Date if Yes : How was that treated? Paps showed HPV negative: Y N Unknown Any problems with control of urination? Y N Mammography: Last Time: Any Concern: Dexa Bone Scan: Last Time: Any Bone Loss Use of Hormones Y N P If Yes which ones and for What purpose: Are you still on any hormones: Sexual History: Sexual Orientation: Heterosexual Homosexual Bi- Sexual Asexual Sexually Active: Y N P Healthy Libido: Y N P Sexually Satisfied: Y N P Painful Intercourse: Y N P
7 Sexually Transmitted Infection: Y N P If yes, please list: What methods of birth control or safe sex practices are you currently using or interested in using? Musculoskeletal: Weakness: Y N P Arthritis: Y N P Stiffness: Y N P Leg cramps: Y N P Tremors: Y N P Pain: Y N P Nervous: Paralysis: Y N P Sciatica: Y N P Tingling/numbness: Y N P Carpal tunnel: Y N P Seizures: Y N P Fainting: Y N P TMJ Syndrome: Y N P Disc Disease: Y N P Mental/Emotional: Which words best describe you? Lacking Dreams Without passion or purpose Anticipate Failure Isolated/Lonely Lacking Self Worth Overly Responsible Difficulty Letting Go Lacking Faith Overly Controlling Guilty Judgmental Self- Critical Frustrated/Angry Impatient Indecisive/No Confidence Lacking Trust Neurotic/Obsessive Anxious In A Rush Abuse Victim Memory Problems Exercise: What types? How many days a week? How long a session? Hobbies: Sleep: How many hours per night: How long does it take you to get to sleep? Do you sleep through the night uninterrupted? Y N If you wake up regularly, what is the reason? Nightmares: Y N P Wake Refreshed: Y N Why not: Grinds Teeth: Y N P Snores: Y N Apnea: Y N Unknown Sleepwalk: Y N Nap During Day: Wants To But Can t Do Not Need No Does Nap At This Time Usually Appetite Good? Y N P Food: Foods you crave?
8 Foods you dislike? Foods that don t sit well? Toxin Exposure: Did you grow up near any refinery, or polluted area, or in home with leaded paint? If so, what sort of pollution were you exposed to? Have you had any jobs where you were exposed to solvents, heavy metals, fumes, or other toxic materials? Have you ever had health problems when you put in new carpeting, painted your home, new cabinets, or did other refurbishing? Are you particularly sensitive to perfumes, gasoline, or other vapors? Do you use pesticides, herbicides, other chemicals around your home? Home Life: Active Spiritual practice: Y N P How Happy are you with the direction of your life (1 not happy- 10 Very happy)? Do you have a good support network? Supportive Partner/Spouse/Family/Friends? Most Significant Relationship: Healthy/Excellent Unhealthy/Abusive If abusive, list how: Emotional Physical Other If you have children, good relationship? Do you enjoy your work? What do you do for fun /stress release? How committed are you towards making valuable changes: Somewhat Moderately Very
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