MEDICAL INFORMATION

GENERAL INFORMATION

Name:
Last Name:
Email Address:
Mobile:
Phone:
Gender :
Male    Female
Nationality:
Age:
Patient's Address:
Date of Birth :

Contact Person in case of emergency

Name:
Email Address:
Phone
Address:
Patient's current "primary" diagnosis and original diagnosis date:
Secondary diagnosis:
Other medical issues:

 

Confidential Medical History

Cancer:

Have you ever been diagnosed with:
Cancer?     Yes    NO
Type?
When?
Status?

Neurological System:

Vision decrease

Black Spots

Nistagmus

Muscle Weakness/Wasting

Hyperreflexia

Walking Difficulties

Decreased Hand Strength

Fainting

Speech Problems

Numbness in Extremities

Tingling Sensation or Twitching

Decreased Sense of Touch

Spasticity

Cardiovascular:

Myocardial infarction   Yes    No
when?
Angina pectoris
Tachycardia
By-pass Surgery when?
High blood pressure
Low blood pressure

Circulatory:

Poor arterial circulation

Poor venous circulation

eg cramps

Tired legs

Swollen ankles

Varicose veins

Tingling in arms and leg

Falling asleep hand/legs

Leg ulcers

Neurology:

Hyporeflexia

Depression

Loss of Memory

Headaches

Sleep Disturbances

Dizziness

Chronic Migraines

Reduced Vitality

Pulmonary System:

Asthma

Chronic bronchitis

Emphysema

Tuberculosis

Chronic cough

Chronic sinusitis

Allergic sinus problem

hronic allergic rhinitis

Sinus headaches

Chronic nose bleeds

Chronic colds

Confidential Medical History 2

Gastrointestinal issue:

Acid indigestion
Yes    No
When :

Bloating
Yes    No
When :

Ulcer
Yes    No
When :

Loss of appetite
Yes    No
When :
Rapid weight gain
Yes    No
When :

Rapid weight loss
Yes    No
When :

Overweight problem
Yes    No
When :

Pancreatitis
Yes    No
When :
Hepatitis : Yes    No
Type:
Gall stones
Diarrhea

Rheumatic Screen:

Soft tissue rheumatism

Articular rheumatism

Joint pain
Back pain

Rheumatoid arthritis

Endocrine Screen:

Diabetes mellitus

Thyroid dysfunction

Male –low labido
Adrenal gland dysfunction

Menopause (hot flashes, etc.)
Nutritional supplements:
Overactive
Under active

Allergy History:


Have you ever had an allergic reaction to any of the following:
Food, esp. eggs and other dairy products.
Last vaccination date:
Hay fever?


Do you smoke?


Daily alcohol consumption?


Are you allergic to any medications?
Yes    No
If yes, please explain

Patient History

Do you have or have you had any of the following?
Yes    No
If yes,
Cancer

Leukemia

Anxiety

Diabetes

Hypertension
Arthritis Lung

Thyroid

Kidney

Problem

Prostate

Fatigue

Hormone issue

Heart

Stroke

Mental

Disorder
Previous occasions when you were hospitalized (other than those identified above):
Date


Procedure


Have you been on growth hormone therapy? Yes    No


If yes, how long?


Number of IU's of HGH injected per week?

Family History


Member of your family with a history of the following conditions
Cancer

Leukemia

Anxiety

Diabetes

Hypertension
Arthritis Lung

Thyroid

Kidney Problem

Prostate

Fatigue

Hormone issue

Heart

Hormone

Mental Disorder
[MEN ONLY] What was the date and result of your last PSA test, if any?
Yes   No

What was the date and result of your last test?
Date :
Result :
[WOMEN ONLY] Do you have periodic mammograms?
Yes   No

What was the date and result of your last test?
Date :
Result :

Physical Limitations

Do you need assistance when walking?    Yes    No
Do you require a wheelchair?    Yes   No
Other requirements
What do you intend to accomplish with the treatment you are seeking?
Disease history (of primary diagnosis): a very detailed statement of the patients past medical history is needed.
Results of MRI, CT, X-ray, and/or EMG, etc, AND results of Laboratory Examination (Blood Test and Others). ***Please attach results to intake package or scan and email results!
Current symptoms: a detailed statement of the patient's current medical issues.


Current medications :


Please include any over the counter medications and supplements.
Medication/Supplement
Dosage
Times
Reason
Do you have any allergies to medications and/or other substances?
Yes    No


If yes, please explain:
Personal and Family Medical History: (Please comment on all genetic/familial disorders.)
Grand Parents
Mother
Father
Siblings
Please list all past medical issues and/or surgeries: include date of occurrence, type of treatment received and overall outcome.
Surgery/procedure
Date
Result
Does the patient have any metal plates/rods/or any other implanted device or tissue that should be known to the doctor?
Yes   No


If yes, please describe.
Does the patient have any communicable illness such as HIV, TB and/or Hepatitis, etc?
Yes    No


If yes, please explain.
Is there or has there ever been a presence of malignant tumors and/or cancer diagnosed?
Yes    No


If yes, please explain in detail.
Does the patient have a pacemaker?
Yes    No


If yes, please explain why and what type.
Does the patient have a continuous medication pump?
Yes    No


If yes, please explain why and what type.
Does the patient have a feeding tube?
Yes    No


If yes, please describe the type of tube and the type of pump used.
Is it used for feeding and/or medications?
Is the patient on a ventilator and/or have breathing problems?
Does the patient have a tracheotomy?
Does the patient require suctioning?
Does the patient require oxygen?
***Please bring with you all the supplies you will need for trach care and suctioning.
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