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Health History Form - BioHarmony Rejuvenation Center

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  • 1. 1143000-733425BIOHARMONY REJUVENATION CENTER<br />Dr. Christopher F. Bosco, DC<br />Health History Please Print<br />Form<br />Name _________________________________________________________Date_________________<br />Home Phone ( ) ____________ Work Phone ( ) ______________ Cell Phone ( ) ____________<br />Address: ____________________________________________________________________________<br />City ________________________________________________ State ___________ Zip ____________<br />Sex: ______ Age: _____ Birth Mo/Day/Yr: _____________ Height: __________ Weight ___________<br />What types of work have you done that would expose you to chemicals, pesticides, metal products, <br />herbicides, cleaning products, etc.? For how long were you exposed to these types of products?<br />____________________________________________________________________________________<br />What is your energy level? Low 1 2 3 4 5 6 7 8 9 10 High<br />Name of Primary Care Physician Phone number Date of last visit--purpose<br />____________________________ (_____) _____________ ____________________________<br />Name of Dentist Phone number Date of last visit-purpose<br />____________________________ (_____) _____________ ____________________________<br />General Background<br />1. Ethnic group:<br /> __ Caucasian __ African-American __ Asian__ Hispanic __ American Indian __ Other: ____________<br />2. Marital Status: Currently:_ Single _ Married_ Divorced _ Separated _ Widowed<br />If married, how long? __________________ If divorced, how long? ________________<br />3. Children:<br />Number, total: ________ Number, girl(s): __________ Number, boy(s): ________<br />4. What are your one or two primary reasons to BioBalance? ___________________________________<br />____________________________________________________________________________________ <br />5. When did you last feel well (absent of all symptoms)?: _____________________________<br />Reason 1 (explain): ____________________________________________________________________<br />Date symptoms first occurred: ___________________________________________________________<br />Frequency of symptoms: _______________________________________________________________<br />What makes condition improve? __________________________________________________________<br />What makes condition worse? ___________________________________________________________<br />Do you think this problem will resolve itself? _ Yes _ No<br />Previous treatment:<br />Name of practitioner Phone number Treatment/outcome<br />____________________________ (_____) _____________ ___________________________________<br />____________________________ (_____) _____________ ___________________________________<br />____________________________ (_____) _____________ ___________________________________<br />6. Who referred you to our clinic?<br />__ Self __ Referring medical professional __ My family__ Friend __ Other: __________________<br />7. Significant birth events:<br />Premature birth? __ Yes __ No If Yes, how many days premature? __________<br />Other:___________________________________________________________________________________________________________________________________________________________________<br />8. List all childhood illnesses (continue on reverse if necessary):<br />Colic, Earaches, Mumps, Measles, Chickenpox, etc…<br />____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<br />Infections: Chronic, Yes, No, None, Some, Moderate, Extreme<br />Explain: ________________________________________________-<br />Antibiotics Use: None, Some, Moderate, Extreme<br />Additional Illnesses and Date(s)<br />____________________________________________________________________________________<br />____________________________________________________________________________________<br />____________________________________________________________________________________<br />9. List all surgeries (continue on reverse if necessary):<br />Tonsils ________Adenoids ________Appendix ________Gallbladder ________ Wisdom Teeth _________ Any Problems? _____________<br />Additional Procedure s Date(s)<br />________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<br />10. List all injuries (continue on reverse if necessary): Procedure and Date(s)<br />____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<br />11. Have you been diagnosed with any of the following (in past or current medical condition):<br />( ) Heart disease ( ) Kidney problems ( ) Stroke( ) Seizure disorder ( ) Thyroid problems ( ) Arthritis<br />( ) High blood pressure ( ) Glaucoma ( ) Diabetes( ) Obesity ( ) High cholesterol ( ) Ulcers<br />( ) Periodontal disease ( ) Oral gum / bone problem ( ) Cancer( ) Whiplash ( ) Liver disease ( ) Cataracts( ) Depression ( ) Manic-depressive disorder ( ) Other (please list):_________________ ____________________________________________________________________________________<br />12. List any other medical conditions you have had, and dates (do not include common cold or flu):<br />____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<br />How often do you get a cold? ____________________________________________________________<br />13. If your family has a history of any of the following, please: A. Circle the condition and B. Write ‘F’ for father, ‘M’ for mother, and ‘S’ for sibling within the parentheses:( ) Acne ( ) Anaphylactic Reactions ( ) Asthma( ) Alcoholism ( ) Cancer ( ) Diabetes<br />( ) Depression/Moods ( ) Eczema ( ) Epilepsy( ) Early senility ( ) Herpes ( ) Hepatitis<br />( ) Heart disease ( ) High blood pressure ( ) Hysterectomy( ) Intestinal Disorders ( ) Kidney Disorders ( ) Manic-depressive disorder( ) Neurological Disorders ( ) Obesity ( ) Stroke<br />( ) Schizophrenia ( )Seizure Disorders ( ) Thyroid Condition<br />Do you suffer from headaches? __ Yes. __ No. If Yes, how often per month? ______________________<br />15. List all medications, prescription and over-the-counter, you are now or have been taking. For prescriptions note the name of the physician who prescribed (continue on reverse if necessary):<br />Prescription Medication Physician Dosage /How Long<br />1._______________________ __________________________ ___________________________<br />2._______________________ __________________________ ___________________________<br />3._______________________ __________________________ ___________________________<br />4._______________________ __________________________ ___________________________<br />5._______________________ __________________________ ___________________________<br />6._______________________ __________________________ ___________________________<br />7._______________________ __________________________ ___________________________<br />8._______________________ __________________________ ___________________________<br />17. List all supplements/alternative remedies (vitamins, minerals, herbs, etc.) you are now taking and/or<br />alternative treatments you are undergoing. Attach a separate sheet if necessary:<br />Supplement Brand Size (mg, mcg, etc) Daily Dose<br />1._________________________________ ________________________ _______________<br />2._________________________________ ________________________ _______________<br />3._________________________________ ________________________ _______________<br />4._________________________________ ________________________ _______________<br />5._________________________________ ________________________ _______________<br />6._________________________________ ________________________ _______________<br />22. What is your most important health goal?<br />________________________________________________________________________________________________________________________________________________________________________<br />Rate your overall energy level: Low Med High Very High<br />Rate your energy level in the morning: Low Med High Very High<br />Rate you energy level in the afternoon: Low Med High Very High<br />Rate your energy level in the evenings: Low Med High Very High<br />Rate Your General Health: Very Poor Poor Good Great Excellent<br />What is your activity level? Exercise 1-3x per week__. 3-5x per week__. 5-7 week__<br />Light (10 -15 min) __. Moderate (15-30 min) __. Aggressive (40-80 min) __<br />Aerobics Y or N<br />Light (10 -15 min) __. Moderate (15-30 min) __. Aggressive (40-80 min) __<br />Weights Y or N if yes: Light ___. Medium ___. Heavy ___<br />What is your exercise/weight goal? __________________________________________________________<br />________________________________________________________________________________________<br />Rate your interest in Overall Wellness. Circle one. Low Med High Very High<br />How Motivated are you to make the changes necessary to increase your Overall Wellness? Circle.<br />Low Med High Very High<br />What should you do that you know you don’t when it comes to your health? ________________________ _________________________________________________________________________________________<br />What do you have the most trouble changing in your health habits? _______________________________<br />______________________________________________________________________________<br />PLEASE READ CAREFULLY If you have any of the following please continue:<br />Check the appropriate answers – underscore or circle particular symptoms and/or level of severity.<br />If you had a moderate to severe condition in the past but no longer have it, circle “in past”. Circle the symptom and put approximate dates or age when you had it (if you can remember).<br />ALLERGY: List all known allergies Foods, Grasses, Trees Etc. (including medications): ___ No known allergies__ Sulfa __ Latex __ Aspirin __ Lydocaine __ Penicillin __ Beef Products<br />________________________________________________________________________________________________________________________________________________________________________<br />1. Have you had any type of allergy testing?<br />( ) Yes. ( ) No. Name of test? ________________________ When? _________________________<br />2. Do you have inhalant allergies? ( ) Yes. ( ) No. ( ) in past<br />( ) trees ( ) grasses ( ) molds ( ) dust ( ) smoke ( ) other<br />3. List other allergies you have: __________________________________________________________<br />____________________________________________________________________________________<br />4. Have you ever had a serious allergic reaction? ( ) Yes ( ) No<br />If yes, to what? _______________________________________________________________________<br />Give approximate date and symptoms: ____________________________________________________<br />If yes, what treatment did you receive? ____________________________________________________<br />5. Do you have a chronic sniffle or cough? ( ) Yes ( ) No ( ) In past<br />ASTHMA/RESPIRATORY DISEASE:<br />1. Do you have Asthma? ( ) Yes ( ) No ( ) In past<br />( ) slight ( ) moderate ( ) significant<br />2. Have you been treated for Asthma? ( ) Yes ( ) No<br />3. Have you tried nutrition? ( ) Yes ( ) No<br />4. Have you had allergy testing to document the cause of your Asthma?<br />( ) Yes ( ) No<br />5. Have you had pulmonary function tests? ( ) Yes ( ) No<br />6. Do you have chronic cough? ( ) Yes ( ) No<br />7. Do you have phlegm? ( ) Yes ( ) No<br />8. Do you have trouble breathing? ( ) Yes ( ) No<br />CURRENT LIFE EVENT STRESS<br />Circle any of the following if it has occurred in the last year. Put an X if it occurred in the last two years.<br />1. Death of spouse………………………………………………………………….… 100<br />2. Divorce ………………………………………………………………………….……. 73<br />3. Marital separation from mate ………………………………………………………...65<br />4. Detention in jail or other institution …………………………………………….…….63<br />5. Death of a close family member ………………………………………………..……63<br />6. Major personal injury or illness ………………………………………………………53<br />7. Marriage ……………………………………………………………………….……….50<br />8. Being fired from work/Lost job..………….………………………………….………..47<br />9. Marital reconciliation with mate ……………………………………………….……...45<br />10. Retirement from work/drastic pay change………………………………………….45<br />11. Major change in the health or behavior of a family member .…………………...44<br />12. Pregnancy.……………………………………………………………………..………40<br />13. Sexual difficulties..……………………………………………………………..……...40<br />14. Gaining a new family member (e.g., birth, adoption. Oldster moving in, etc.)….39<br />15. Major business readjustment (e.g., merger, reorganization, bankruptcy, etc.) .. 39<br />16. Major change in financial state (e.g. a lot worse off or a lot better than usual)….38<br />17. Death of a close friend ………………………………………………………..………37<br />18. Changing to a different line of work ………………………………………………….36<br />19. Rate your level of stress on scale of 1 to 5. (1= low stress, 5=high stress). Circle.<br />Stress level: at work (or school) 1 2 3 4 5 Home 1 2 3 4 5 Overall 1 2 3 4 5<br />20. Rate your level of contentment with your life right now, on a scale of 1 to 5. (1=not happy at all, 5=very content) Circle. 1 2 3 4 5<br />Sign_______________________________________________Date____________________<br />