Clymer Healing Center Woodlands Healing Research Center

5916 Clymer Rd., Quakertown, PA 18951 * 215-536-8001 * Fax 215-536-9099

5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034

 

ADULT HEALTH HISTORY QUESTIONNAIRE

(Ages: 13+ yrs old)

Click here to Return to New Patient Information Page

Name:    Date Form Completed:

Gender: Female Male   Date of Birth:      Age:

MEDICATION ALLERGY AND INTOLERANCE: List any medication or supplement you are allergic to or which caused unpleasant side effects; include the name of the substance, the age it occurred, how it was taken (mouth, vein, etc), what reaction occurred, and the treatment if given. Use additional sheets if necessary.       

Prescription Medication Date Route given Reaction Any Treatment Given
Example: Penicillin    02/2002 By mouth Hives, breathing difficulty None

MEDICATIONS: List medicines, both prescribed by a physician and obtained without a prescription (those that you can buy on your own), that you are currently taking or have taken recently. Complete as much as you are able. Including the name of the medicine, the strength of the medicine (dosage), how often you take it (frequency), date started and date stopped if you are no longer are using it. Please bring all your medication to your appointment. Use the other side of this sheet or additional sheets if necessary.

Medication Dose Frequency (times per day) Started Stopped
Example: Benadryl 25mg 1 pill 2 times per day 1990 ---------

VITAMINS, MINERALS, AND OTHER NUTRITIONAL SUPPLEMENTS:

As above, please list your nutritional supplements to include vitamins, minerals, herbs, homeopathic remedies, folk remedies, and other nutritional or alternative therapies. Please include the form of the supplement (pill/liquid, etc), and the dosage (mg, IU, etc). Please bring all your supplements to your appointment. Use the other side of this sheet or additional sheets if necessary.

Vitamin/Herb/Supplement Dose Frequency (times per day) Started Stopped
Example: Vitamin C 500mg 1 pill 3 times per day 06/01/2000 ---------

Antibiotics: List the number of times you have been on antibiotics such as Penicillin, Tetracycline, Amoxicillin, Keflex, Ceclor, Erythromycin, or other antibiotics: NO      YES, The number of times given antibiotics:

Please check any of the reasons listed as to why  you were prescribed antibiotics, include as many as apply:

Acne/skin condition   Colds    Tonsillitis/Strep Throat    Ear Infection(s)     Bladder/Kidney Infection

Other:

Steroids: Have you ever taken an oral cortisone preparation such as Prednisone, Decadron, Medrol, or others? If yes, state how many times.  NO    YES, The number of times given steroid pills:

Have you received a cortisone type "shot" such a Depo Medrol, Decadron, Kenalog, or others?

 NO   YES, The number of times given steroid injections:

CHIEF COMPLAINT: In your own words, what are your main complaints? State the nature and duration of the symptoms:
Severity (of chief complaint): Mild Mild to Moderate Moderate Moderate to Severe Severe
Interferes with my life, how?:
 I am on disability:Social Security Disability (SSD) Private Plan; Date Awarded:
Please list handicaps/disabilities:
Antecedents: When was the last time you were well? What happened after that time?
During the 12 months preceding the onset of your present condition(s), check those that apply and briefly comment:
Was under severe stress:
Moved to new residence or home:
Traveled outside the U.S.:
Involved in wilderness activity:
Experienced an injury:
Experienced fever or acute illness:
Took drugs or medications:
Had chemical or toxic exposure:
   
REVIEW OF SYMPTOMS: Check the symptoms that apply to you. Note whether the symptom is past, now or both:
General:    
Past Now Tired without effort Past Now Fever Past Now Flu like symptoms
Past Now Chills Past Now Night sweat Past Now Cold intolerance
Past Now Heat Intolerance Past Now Weight Gain: lbs Past Now Weight Loss: lbs
Neurological: Past Now Attention Difficulties Past Now Concentration prob's
Past Now Can't Decide easily Past Now Thinking Difficulties Past Now Poor memory (long term)
Past Now Poor Memory (short term) Past Now Disorientation Past Now Hyperactivity
Past Now Constant Movement Past Now Low Activity (Hypo)  
Past Now Sleep too much Past Now Difficulty falling asleep Past Now Frequent awakening
Past Now Nightmares Past Now Restless Legs Past Now Un-refreshed Sleep
Past Now Dizziness Past Now Fainting/Blacking out Past Now Convulsions/Seizure
Past Now Speech problem Past Now Burning sensations Past Now Electrical Zaps
Past Now Numbness Past Now Tingling Past Now Headaches
Past Now Weakness Past Now Clumsiness Past Now Tremors
Past Now Repeats same action(s) Past Now Head Banging Past Now Rocking
Past Now Picking Past Now "Pill rolling" actions Past Now Paralysis
Mental/Emotional:    
Past Now Anxiety/Nerves on edge Past Now Apprehension Past Now Fearful
Past Now Fearful of going out Past Now Other Specific Fear:
Past Now Panic Episodes Past Now Flashback memories:
Past Now Sad/Depressed mood Past Now Hopelessness Past Now Guilt
Past Now Lost of interest in life Past Now Suicidal Thoughts Past Now Suicidal Attempt(s)
Past Now Angry Past Now Irritable Past Now Mood Swings
Past Now Jekyll/Hyde personality Past Now Stress @ work Past Now Stress @ home
PastNow Stress in a Relationship: Explain:
     What are your other major stressors?
Past Now Anorexia Past Now Binge eating Past Now Impulsive eating
Past Now Purging Past Now Sugar cravings Past Now Anti-social behaviors