Health Inventory | InterConnective Health

HEALTH INVENTORY

This information is confidential and will only be released with your signed consent.

CONTACT INFO

Last Name

First Name

Mid Initial

Address

City

State

County

Zip Code

Cell Phone

Home Phone

EMERGENCY CONTACT INFO

Emergency Contact Name

Emergency Contact Phone

Relationship

If Under 18, Parent's Name

If Under 18, Parent's Address

REFERRAL INFORMATION

Referred By

Address

FAMILY PHYSICIAN

Physican Name

Address

FAMILY HISTORY

Check if family history is unknown.

FATHER

MOTHER

SIBLINGS

CHILD

Please indicate blood relatives (children, sisters, brothers, parents, grandparents, aunts, uncles) that apply.

Alcohol / Drug Problem:

Allergy / Asthma:

Anemia:

Arterialsclerosis:

Arthritis:

Binge Eating / Bulimia:

Bleeding Problem:

Cancer:

Endocrine / Hormonal Imbalance:

Diabetes:

Heart Disease:

Skin Disease:

Epilepsy / Seizure:

High Blood Pressure:

High Cholesterol / Fat:

Kidney Disease:

Liver Disease:

Mental Illness:

Obesity:

Stroke:

Suicide:

Thyroid Disease:

Tuberculosis:

Gastro Intestinal Disease:

Syphilis:

Gonorrhea:

PAST HISTORY OF ILLNESS AND MEDICAL PROBLEMS

Surgery: List all surgeries and approximate dates

Broken Bones and/or traumatic injuries

(include all car accidents or concussions)

Other Hospitalizations

Current Health Problems

Example: High Blood Pressure - 10 Years

PAST HISTORY

Acne:

AIDS:

Alcohol / Drug Problem:

Allergies:

Amalgams / Silver Fillings:

Anemia:

Antibiotics more than once a year:

Anorexia:

Anxiety:

Arteriosclerosis:

Arthritis:

Asthma:

Back Pain / Strain:

Binge Eating:

Bladder Infection:

Blood Clots:

Breast Lump:

Bronchitis:

Bulimia (Self-Induced)

Cancer:

Cateract:

Chemical Sensitivity:

Chicken Pox:

Chronic Fatigue:

Colds, frequent:

Colitis:

Congenital Defect:

Counseling:

Depression:

Diabetes:

Ear Infection:

Eczema:

Endometreosis:

Epilepsy / Seizure:

Epstein Barr / Infectious Mono:

Fibrocystic Breasts:

Fibroids:

Gallbladder Problem:

Glaucoma:

Gonorrhea:

Gout:

Hay Fever:

Hearing Problems:

Heart Attack:

Heart Failure:

Heart Problems:

Hemorrhoids:

Hepatitis:

Herpes:

Hiatal Hernia:

High Blood Pressure:

High Cholesterol / Triglycerides:

Hives:

Hypoglycemia:

Insomnia:

Kidney Infection:

Kidney Stones:

Kidney Problems:

Liver Disease:

Menstrual Problems:

Mental Illness:

Migraine:

Nervous Condition:

Neurological Problem:

Overweight (over 20 lbs)

Panic Attacks:

Pelvic Infections:

Pelvic Ulcers:

Periodontal Disease:

Phlebitis:

Pneumonia:

Premenstrual Tension:

Prostate Problems:

Psychotherapy:

Reactions To Vaccines:

Rheumatic Fever:

Root Canal:

Scarlet Fever:

STDs:

Sinusitis:

Skin Problems:

Sleep Disorders:

Stroke:

Suicide Attempt:

Syphilis:

Taken Steroids

(cortisone / prednisone):

Thyroid Problem:

Tonsilitis:

Tooth Problems:

Urine Problems:

Vaginitis:

Vision Problems:

Warts:

Other Notes:

REVIEW OF SYSTEMS

Answers "yes" if you have had these symptoms in the last 6 months.

Chronic Fatigue

Mood Swings

Chronic Depression

Trembling Episodes

Light-headedness

Food Craving

Frequent Infections

Night Sweats

Swollen Glands

Skin Rash

Chills / Fever

Change In Skins / Nails

Change In Wart or Mole

Abnormal Bleeding / Bruising

Change In Hair Loss / Growth

Irritability

Restlessness

Headaches

Dizziness

Balance Problem

Head Injury

Seizure / Convulsions

Poor Memory

Difficulty Concentrating

Fainting

Weakness

Numbness / Tingling

Blurred Vision

Double Vision

Loss Of Any Vision

Halos Around Lights

Excessive Tearing / Itching

Eye Pain

Dark Circles Under Eyes

Date of Last Eye Exam

Loss Of Hearing

Ringing / Buzzing In Ears

Sinus Trouble

Nosebleed

Sore Throat

Hoarseness

Change In Voice

Dental Problems

Dry Mouth Problem

Excessive Salivation

Bleeding Gum

Mouth Breather

Chronic Cough

Bloody / Yellow Sputum

Shortness Of Breath

With Exertion

At Night

Bronchitis

Chest Pain Or Pressure

At Rest

With Exertion

With Stress

With Eating

Down Left Arm, Back, or Neck

Accompanied By Nausea, Sweating, Anxiety

Irregular Heart Beat

Skip Beats

Palpitations

Fast Heart Beat

Heart Murmur

Swelling Feet / Legs

Cold Hands / Legs

Leg Cramps At Night

Joint Pain

Burning Feet

Sore Legs / Feet

Color Change Legs / Arms

Difficulty Swallowing

Pain / Discomfort When Eating

Bad Teeth

Belching

Coating On The Tongue

Canker Sores

Pain Relieved By Eating

Nausea / Vomitting

Trouble Eating Fried Foods

Bloating Of Abdomin

Bowel Gas

Constipation

Black Stool

Clay Colored Stool

Mucus In Stool

Hemorrhoids

Rectal Bleeding

Abdominal Pain

Change In Diet

Pain / Burning Urination

Frequent Urination

Urination At Night

Blood In Urine

Foul Odor To Urine

Low Back Pain

Loss Control Of Urine

Men

Enlarged Prostate

Decrease Urine Stream

Unable To Interrupt Stream

Dribbling After Urination

Pus / Drainage From Penis

Genital Swelling / Rash

Problem With Sexual Function

Women

Complications of Pregnancy

Used Birth Control Pills

Used IUD

Change In Cycle

Spotting Between Periods

Discomfort With Periods

Premenstrual Tension

Vaginal Discharge

Painful Intercourse

Itching

Self Breast Examination

Problem W/ Sexual Function

Lump In Breasts

Abnormal Pap Smears

Infertility

PERSONAL HISTORY

CURRENT MEDICATIONS

Lisa all prescriptions and non-prescription including dosages:

Vitamin and mineral supplements

ALLERGIES

I am allergic to the following medications:

Food allergies and method of testing:

LIFESTYLE

List your favorite foods or cravings:

* PLEASE NOTE :

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