General Patient Information



Fred Bloem, M.D.

4108 Alfalfa Terrace – Olney, MD 20832-2962

Phone: 301-260-2601 – Fax: 240-206-2740

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Instructions for Completion of Patient Medical History for Adults

Please complete this form with as much detail as you can. If symptoms or items do not apply to you, please leave them blank. You may use the following abbreviations: Y=Yes, nl=normal, abnl=abnormal.

Please bring any copies of laboratory test results if available. Don’t be concerned about missing or incomplete information as we can fill in the blanks or obtain missing data later.

Please bring any other relevant items, such as medications, supplements, etc.

There are two ways to complete this form:

1. Electronically (preferred)

Complete the information on your computer. It is easy to double click on the red lines and type. You may then e-mail the file to me or take it to my office on a CD, a USB flash drive or other portable medium. You may also print a copy of the completed form.

2. Handwritten

Please print this form and write in your personal information and/or use a separate sheet if you need more space. When using separate sheets, please use numbers to correlate your information with the items on this form.

Please understand that when you e-mail or fax this form ahead of time, that Dr. Bloem does not typically review the medical history form before he meets with you. This form will be reviewed in your presence to allow you to elaborate on any information that requires clarification.

Please complete this form with as much detail as you can. Please indicate positive findings by 1) entering text, 2) entering Y(es), or 3) entering a number indicating severity on a scale of 1 to 10 (e.g., 1/10 is mild pain and 10/10 is intense pain). If the items do not apply to you simply leave the spaces blank.

1. General Patient Information

Full Name: First_Middle_Last

Date of birth: ___

Place of birth: ___

Address: Street_Apt_City_State_Zip

Phone (home): ___

Phone (work): ___

Phone (mobile): ___

Fax: ___

E-mail (work): ___

E-mail (personal): ___

Emergency contact (name of person): ___

Emergency contact (phone): ___

Pharmacy phone: _______________ Pharmacy fax: _______________

How did you learn about Dr. Bloem? ___

2. Health Insurance

Health insurance company: ___

Name of primary policy holder: ___

Health insurance policy ID number: ___

Group Plan number: ___

Health insurance telephone number: ___

Other insurance related identifying information (e.g., RxBIN, RxPCN, RxGRP, Plan Number): ___

3. Healthcare Practitioners Consulted

Current primary care physician name/practice name, specialty, telephone number, and fax number: Name_Specialty_Phone_Fax

Dates of first visit and last visit: ___

Main reasons for seeing this physician (e.g., routine physicals, diabetes care): ___

Other healthcare practitioner name, specialty, telephone number, and fax number (copy this section as often as necessary if there are multiple practitioners that you have consulted with): Name_Specialty_Phone_Fax

Dates of first visit and last visit: ___

Main reasons for seeing this health practitioner: ___

4. Active Medical Problems

Please list your current medical problems, and describe the date of onset, how the diagnosis was made, treatments and response to these. Please list any emotional stresses or traumas that occurred prior to your illness or since. Example: 1970: Diabetes, diagnosed based on symptoms of fatigue and frequent urination and confirmed with high blood sugar levels. Used to be on oral medication but am now taking insulin.

Date_of_onset/diagnosis_Problem_Treatment_Response

___

5. Main Reasons for Seeking Help Now

Please explain why you are seeking help from me now (e.g., symptoms have worsened; symptoms have not responded to treatment; concern about long-term complications).

___

When was the last time you felt well?

___

6.1 Medications, Remedies, Nutritional Supplements

Please list all the prescription and nonprescription medications, remedies, and nutritional supplements that you are taking. Please list start date, the dose, the frequency, the brand/manufacturer, the prescribing physician or the person who recommended these, the reason why you are taking them, how well they are working, and whether or not you are experiencing any side effects. Example: 1990: Prozac 40 mg once daily, prescribed by Dr. Jones for depression. Used to be effective to alleviate depression initially but have found it to be less effective recently. Have experienced weight gain since starting this and am looking for an alternative solution.

Start_Date_Medication_Brand_Manufacturer_Dose_Frequency_Prescriber_Reason_Effectiveness_Side_effects?

___

Are you now using oral or injectable contraceptives or an IUD (intrauterine device)?

___

6.2 Past Medication History

Have you ever used any of the following medications? If so, how frequently and for what duration?

Oral contraceptives (birth control pills)? ___

IUD (intra-uterine contraceptive device)? ___

Depo Provera? ___

Premarin? ___

Provera? ___

Steroids (e.g., prednisone, cortisone shots) ___

Antibiotics? ___

Have you ever been a paid or volunteer participant in a medical research study? If so, please provide details of pharmaceutical and other exposures.

___

7. Allergies

Please list any allergies to medications, foods, or other allergens, and describe your reaction to these allergens.

___

Any allergies to wheat ___ , dairy ___ , others ___

Have you ever been tested for allergies? ___ Copies of reports? ___

Have you ever been treated for allergies? ___

8. Chemical Sensitivities

Do you have chemical sensitivities (e.g., perfume, cigarette smoke, paint, construction materials, carpet)? ___

9. Electromagnetic Sensitivities

Do you have electromagnetic sensitivities (e.g., computers, TVs, video screens, radios, fluorescent lights and “low-energy” light bulbs, cell phones and cordless phones, electric heaters and air conditioners, elevators and escalators, wireless devices such as microphones, headsets, and computer networks, transformers and power supplies, battery chargers, etc., battery back-up systems for computers (UPSs), surge suppressor power strips, amplifiers and speakers, dimmer switches, projectors, electric utility meters and distribution panels, inverters in solar-electric systems)? ___

10. Hospitalizations

Please list all the times you were hospitalized, the reasons for hospitalization, the treatments and outcome. Example: 1980: Pneumonia, hospitalized for 7 days, treated with antibiotics and had a full recovery.

Date_Reason_for_hospitalization_Treatment_Outcome

___

11. Surgeries or Medical Procedures

Please list all the times you had surgery or medical procedures.

Date_Surgical_procedure_Reason_Outcome_Complications?

___

Are any of your organs or body parts missing (e.g., gallbladder, appendix, tonsils, adenoids, ovaries, testicles, uterus, part of intestinal tract)? ___ If so, please provide details.

___

12. Past Medical Problems

Please list any health issues that have now resolved or that are dormant and that are not symptomatic now (e.g., childhood illnesses, sexually transmitted disease, other infectious or toxic exposures, accidents, major trauma, scars (please give location)). Example: 1980: recurrent ear infections during childhood and received multiple courses of antibiotics until age 10.

Start_date_Problem_Date_resolved

___

13. Education and Occupation

Please briefly describe your occupation and the activity you perform (start date, part-time/full-time?): ___

If you have a second job or occupation, please briefly describe it and the activity you perform (start date, part-time/full-time?): ___

What are the days and hours that you work? ___

Any occupational stresses or hazards (e.g., mental or physical stress, toxic exposures (mold, chemicals, etc.), repetitive motions, sick building syndrome)? ___

Previous occupations or work experiences: ___

Highest level of education: ___

14. Religion and Associated Customs

Religion: ___

Please describe any religious beliefs, customs, or practices with health implications (e.g., fasting, dietary customs): ___

Are spiritual issues important to you? ___

What do you do in the spiritual areas of your life? ___

15. Family

Marital status: ___

If married, length of current marriage: ___

If not married, have you previously been married? ___ How many times? ___ Length of each marriage? ___

Occupation of spouse or other adult(s) in family: ___

Names, ages, and relationship* of other people who are in your household. *E.g., husband, sister, brother, roommate.

Name_Age_Relationship*

___

16. Family History

Are there any diseases that are common in your blood relatives (grandparents, parents, and children)?

Please use the following abbreviations.

F=Father; PGF=Paternal grandfather; PGM=Paternal grandmother; FB=Father's brother; FS=Father's sister

M=Mother; MGF=Maternal grandfather; MGM=Maternal grandmother; MB=Mother's brother; MS=Mother's sister

B=Brother; SR=Sister; S=Your son; D=Your daughter.

Please number individuals in the same generation (e.g., S1 is your oldest son; MB2 is your mother's second oldest brother).

Please indicate age of onset, cause of death and age of death.

Diabetes ___ , hypertension ___ , heart attack ___ , stroke ___ , sudden death ___ , breast cancer ___ , colon cancer ___ , thyroid disease ___ , allergies ___ , asthma ___ , bleeding tendency ___ , epilepsy ___ , gallbladder ___ , glaucoma ___ , hearing loss ___ , hypoglycemia ___ , kidney disease ___ , liver disease ___ , lupus ___ , multiple sclerosis ___ , fatigue ___ , rheumatoid arthritis ___ , tuberculosis ___ , overweight/obesity ___ , mental illness ___ , depression ___ , alcohol abuse ___ , drug abuse ___ , other ___

17. Review of Systems

Please indicate if you have any of the following symptoms. Please describe the date of onset, the severity on a scale of 1 to 10 (most severe) or yes, as appropriate; whether the complaint is constant or whether it comes and goes; any contributing factors; things that make it worse and that make it better; as applicable, the location of the symptom or complaint. If symptoms or items do not apply to you, please leave them blank.

17.1 General

Cold intolerance ___ , cold hands and feet ___ , fatigue ___ , difficulty waking up in the morning ___ , feeling like you could take a nap any time ___ , fatigue in the afternoon ___ , difficult to recover after physical activity ___ , headache ___ , headaches in the morning ___ , headaches in the afternoon ___ , headaches with exertion or stress ___ , “splitting” type headaches ___ , fluid retention ___ , feeling jittery ___ , feeling shaky ___ , inward trembling ___ , hot flashes ___ , daytime sweats ___ , night sweats ___ , perspire easily ___ , always thirsty ___ , always hungry ___ , you look older than you are ___ , feet too hot at night ___

Does your face look thinner? ___

Insomnia ___ Time you go to bed, fall asleep and wake up: ___

Difficulty falling asleep ___ , waking up during the night ___ . Why? ___ Hard to fall asleep again? ___

Do you use a sleep aid? ___

How many hours of sleep do you require to function properly? ___

Is the room completely dark when you sleep (i.e., no lights on in the room; no light from street lamps coming through the windows)? ___

17.2.1 Weight and Height

Height: ___ Have you lost height? ___ Do you have vertebral fractures (compression fractures in the spine)? ___

Current weight and date weighed: ___

Is your waist girth equal or larger than hip girth? ___

Weight during childhood (normal, under/overweight) ___ , weight during adolescence ___ , weight during adulthood ___ , weight fluctuations ___ , weight gain ___ , weight loss ___ , abdominal weight gain ___ , weight gain when under stress ___ , difficulty gaining weight ___

Clothes size(s) ___

What causes you to lose or to gain weight (e.g., type of food, amount of food, emotional ties to food, stress, depression, food cravings, slow metabolism, lack of exercise)? ___

17.2.2 Developmental History

Any problems while you were in your mother’s womb? ___ , duration of gestation (number of weeks)? ___ , perinatal problems (around the time of your birth)? ___

While you were in womb, did your mother smoke cigarettes or use alcohol (including wine or beer), or any prescription drugs or street drugs? ___

Were you breast fed? ___ For how long? ___ Were you fed infant formula? ___ For how long? ___

Any problems with learning, attention, concentration, or dyslexia? ___

Any adverse reactions to childhood immunizations? ___

Any other developmental or childhood problems? ___

17.3 Mental Health

Depression ___ , anxiety ___ , obsessive compulsive behavior or thinking ___ , mania ___ , delusions ___ , feelings of paranoia ___ , memory problems ___ , trouble concentrating or focusing ___ , easily confused ___ , loss of interest or motivation ___ , easily agitated ___ , easily upset ___ , suicidal thoughts ___ , suicide attempts ___

17.4 Stress

Financial stress ___ , work related stress ___ , marital stress ___ , family related stress ___ , other stress ___

What activities do you perform to reduce stress? ___

How often do you perform these activities? ___

Do you believe stress is presently reducing the quality of your life? ___

Do you feel significantly less vital than you did one year ago? ___

Are you happy? ___

Do you feel your life has meaning and purpose? ___

Do you like the work you do? ___

Have you ever experienced major losses in your life? ___

Do you spend the majority of your time and money to fulfill responsibilities and obligations? ___

Would you describe your experience as a child in your family as happy and secure? ___

17.5 Nervous System

Paralysis ___ , weakness ___ , tremors ___ , numbness ___ , tingling ___ , loss of feeling ___ , other abnormal sensations ___ , dizziness ___ , dizziness when standing up ___

17.6 Hair

Dry hair ___ , hair loss ___ , thinning of hair (scalp, eyebrows, elsewhere?) ___ , bald spots ___ , excessive/unwanted hair ___ , premature graying of hair ___

Decrease of hair under arms ___ , in pubic area ___

Decrease of fatty tissue in pubic area (flat “mount of Venus” in women) ___

17.7 Skin and nails

Dry skin (scalp, face, arms, trunk, legs, feet?) ___ , scaly skin ___ , cracked skin ___ , acne ___ , pimples ___ , skin infection ___ , eczema ___ , rash ___ , rosacea ___ , sores/ulcers ___ , skin tags ___ , thinning skin ___ , weak, brittle, peeling or splitting nails ___ , paler complexion ___ , thin vertical wrinkles on upper lip ___ , sagging skin (e.g., cheeks) ___ , difficulty healing ___ , stomach and buttocks are skinny ___ , wrinkling of skin ___ , itching ___ , reddened skin of palms ___ , tattoos ___ , piercings ___

17.8 Bones and Joints

Joint stiffness ___ , morning joint stiffness ___ , joint pain ___ , bone pain ___ , TMJ (temporomandibular joint disorder) ___ , neck pain ___ , shoulder pain ___ , carpal tunnel syndrome ___ , back pain ___ , hip pain ___ , other ___ , osteoporosis ___ , osteopenia ___ , bone density measurement done? ___

17.9 Muscles

Muscle aches ___ , muscle cramps ___ , muscle weakness ___ , muscle stiffness ___ , flabby muscles ___ , tense neck muscles ___

17.10 Eyes

Vision problems ___, glasses for reading or for nearsightedness ___, Lasik surgery ___ , blurred vision ___ , dry eyes ___ , other eye irritation ___ , mucus in eyes ___ , excessive tearing ___ , itchy eyes ___ , itching, rash or irritation of eyelids ___ , inability to see colors as brightly as before ___ circles under eyes ___ , yellowish cast to eyes ___ , cataracts ___ , glaucoma ___

17.11 Ears

Problem hearing ___ , ringing in ears ___ , itching or irritation of outer ear or ear canal ___ , noise intolerance ___ , excessive amounts of ear wax ___

17.12 Nose and Sinuses

Congestion ___ , discharge/mucus ___ , postnasal drip ___ , bleeding ___ , trouble smelling ___ , sinus problems ___ , hay fever ___

17.13 Teeth and gums

Any mercury amalgams (aka “silver fillings”) ___ , root canals ___ , extractions ___ , implants ___ , caps ___ , braces ___ , other dental procedures ___ bleeding gums ___ , receding gums ___ , problems with dental occlusion (e.g., crooked teeth, missing teeth) ___, teeth grinding ___.

How frequently do you have routine dental care? ___

Are you under the care of a regular dentist? ___

Are you under the care of a holistic or biological dentist? ___

17.14 Mouth, Throat and Neck

Sores ___ , discoloration ___ , difficulty swallowing ___ , painful swallowing ___ , loss of taste ___ , tongue problems ___ , coated tongue or coating of “fuzzy” debris on tongue ___ , thickening of neck ___ , enlargement of thyroid gland (goiter) ___ , snoring ___

17.15 Chest, Heart and Lungs

Asthma ___ , shortness of breath at rest ___ , shortness of breath with exertion ___ , palpitations ___ , pain of the chest wall ___ , low blood pressure ___ , high blood pressure ___ , history of anemia as determined by a blood test ___

Blood pressure at rest: ___

Pulse rate at rest: ___

Blood type: ___

17.16 Breasts

Men and women: enlargement of breasts? ___

Women only: Fibrocystic or lumpy breasts ___ , swelling of breasts ___ , breast tenderness ___ , nipple tenderness ___ , inverted nipples ___, nipple discharge ___ , shrinking breasts ___ , breast lumps ___ , skin changes over the breasts ___ , droopy breasts ___

Date and results of last mammogram ___ , last breast thermogram ___

17.17 Abdomen and Gastrointestinal Tract

Abdominal pain ___ , pain, tenderness, soreness, or bloating on left side under rib cage ___ , abdominal cramps ___ , nausea ___ , vomiting ___ , stomach pain, burning, or aching 1-2 hours after eating ___ ; greasy or high fat foods cause distress ___ , lower bowel gas and/or bloating several hours after eating ___ , bitter metallic taste in mouth, especially in the morning ___ , do you frequently use antacids? ___ , heartburn ___ , heartburn when lying down or bending forward ___ , heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine ___ , indigestion and fullness last 2-4 hours after eating ___ , digestive problems that subside with rest and relaxation ___ , ulcers ___ , feeling hungry an hour or two after eating ___ , burping ___ , belching ___ , bloating ___ , sense of fullness during and after meal ___ , bad breath ___ , flatulence ___ , gas immediately following a meal ___ , poor digestion ___ , diarrhea ___ , constipation ___ , roughage and fiber cause constipation ___ , alternating constipation and diarrhea ___ , anal/rectal itching ___ , anal/rectal pain ___ , rectal bleeding ___ , blood in stool ___ , mucus in stool ___ , foul smelling stool ___ , appearance of stool ___ , stool color alternates from clay colored to normal brown ___ , hard, dry, or small stool ___ , greasy stool ___ , difficult bowel movements ___ , fecal incontinence ___ , number of bowel movements you have per day ___ , feeling that bowels do not empty completely ___ , lower abdominal pain relief by passing stool or gas ___ , difficulty digesting fruits and vegetables ___ , undigested food found in stools ___ , history of gallbladder attacks; do you use laxatives or anything else to promote bowel movements? ___

Date and results of last stool guaiac/hemoccult test (testing for blood in stool): ___

17.18 Urinary Tract

Painful urination ___ , burning urination ___ , frequent urination ___ , difficulty urinating or dribbling ___ , urinary incontinence ___ , increased BUN (blood urea nitrogen) as determined by a blood test ___ , having to get out of bed to urinate at night ___ , dark urine ___ , light colored urine___ , cloudy urine ___ , blood in urine ___

17.19 Reproductive Organs

Men and women: Do you have a satisfactory sex life? ___

Loss of libido ___ , lack of satisfaction during sex ___ , increased sex drive ___

Any genital sores, itching, discoloration, blisters, tenderness, discharge, or odor? ___

Do you suspect that you may have a sexually transmitted disease? ___

Men: inability to have an erection ___ , decrease in spontaneous morning erections ___ , decrease in fullness of erections ___ , difficulty in maintaining morning erections ___ , premature ejaculation ___ , method(s) of contraception ___ , fertility problems ___ , results of any infertility evaluation ___

Women: Pain during intercourse ___ , vaginal discharge ___ , vaginal itching ___ , vaginal dryness ___ , do you use tampons? ___ , method(s) of contraception ___ ; contraceptive methods you used in the past ___ ; have you ever used oral or injectable contraceptives or have you had hormone replacement therapy? ___ , for how long? ___

17.20 Menstrual History

Are you still menstruating? ___

When was the first day of your last menstrual period? ___

Age when you had your first menstrual period: ___

If you are no longer menstruating:

Were your menstrual cycles regular when you were younger? ___

Number of days between periods (normal is every 28 to 30 days): ___

Duration of menstrual bleeding: ___

Severity of menstrual bleeding: ___

Severity of menstrual cramping ___

Any PMS symptoms? Mood swings ___ , irritability ___ , depression ___ , loss of self control ___ , breast pain and swelling ___ , acne break outs ___ , cravings ___

For women who are still menstruating:

Are your menstrual cycles regular? ___

Number of days between periods (normal is every 28 to 30 days): ___

Duration of menstrual bleeding (number of days): ___

Severity of menstrual bleeding: ___

Severity of menstrual cramping ___

Any PMS symptoms? Mood swings ___ , irritability ___ , depression ___ , loss of self control ___ , breast pain and swelling ___ , acne break outs ___ , cravings ___

17.21 Female Reproductive history

Any fertility problems? ___ , results of any infertility evaluation ___

How many times have you been pregnant? ___

How many times children did you deliver? ___

How many miscarriages? ___

Abortions? ___

How long did you breastfeed each child? ___

Any pregnancy complications? (e.g., gestational diabetes, preeclampsia, episiotomy done) ___

18. Laboratory Evaluations

Please list date of evaluation and results (normal/abnormal or actual values).

Electrocardiogram (EKG) ___ , chest X-ray ___ , metabolic profile ___ , lipid profile ___ , complete blood count ___ , thyroid hormone testing ___ , other hormone evaluations ___ , PSA (prostate specific antigen) ___ , flexible sigmoidoscopy ___ , Pap smear ___ , other testing ___ ,

Please bring copies of laboratory test results or request copies from physicians who ordered these tests.

19. Tobacco, Alcohol, Drugs, and other Chemicals or Substances

Please include cigarettes, cigars, alcohol, street drugs, glue sniffing, chewing tobacco, and any other.

Please list approximate dates when you started using, when you quit and the amount and frequency of use.

Start_date_Item_Amount_Frequency_Stop_date

___

20. Diet

How would you describe your diet in a few sentences? ___

What are the names of the stores where you buy groceries? ___

Do you buy organic fruit ___ , vegetables ___ , nuts ___ , seeds ___ , grains ___ , meat ___ , poultry ___ dairy ___ ?

Do you follow any particular diet? ___ Name of diet: ___

Please describe your typical breakfast: ___

… morning snack(s): ___

… lunch: ___

… afternoon snack(s): ___

… dinner: ___

… evening snack(s): ___

How many times per week do you eat cereal ___ , potatoes ___ , pasta ___ , vegetables ___ , fruit ___ , bread ___ , ice cream ___ , cake ___ , candy ___ , cookies ___

Do you feel that you eat very little ___ , normal amounts ___ , too much ___

Do you count calories ___ , fat grams ___ ?

Any history of anorexia ___ , binging ___ , purging ___ , or any eating disorder? ___

Is your food mostly cooked? ___ Do you boil ___ , bake ___ , broil ___ , fry ___ , microwave ___ your food?

Oil you use for cooking: olive ___ , coconut ___ , safflower ___ , canola ___ , cottonseed ___ , other ___

Do you eat or drink any food that is genetically modified ___ , has hormones ___ , antibiotics ___ , fungicides ___ , pesticides ___ , trans fats ___ , synthetic colorings ___ , or other additives ___ ?

Percentage of your vegetables that you eat raw: ___

Do you sprout any nuts, seeds, and grains? ___

Please indicate the amounts that you drink: tap water ___ , bottled water ___ , type of bottled water ___ , filtered water ___ , juice ___ , regular soda ___, milk ___ , soy milk ___ , coffee ___ , tea ___ , wine ___ , beer ___ , other ___

What types of sweeteners do you use? White sugar ___ , honey ___ , agave nectar ___ , stevia ___ , xylitol ___ , saccharin ___ , Sweet N Low ___ , aspartame ___ , Splenda ___ , Equal ___ , other ___

Do you use table salt ___ , sea salt ___ , MSG (monosodium glutamate) ___

Do you restrict your salt consumption? ___

Are you irritable if you miss a meal? ___

Do you get lightheaded if you miss a meal? ___

Does eating relieve fatigue? ___

Fatigue after meals? ___

Any cravings for sweets ___ , chocolate ___ , carbs ___ , ice cream ___ , salty foods ___ , other ___

Does eating sweets not relieve cravings for sugar? ___

Must have sweets after meals? ___

Do you depend on coffee to keep yourself going or to get started? ___

How many meals per week do you eat away from home? ___ Where (names and/or types of restaurants)? ___

21. Exercise and Physical Activity

What type of physical activity do you enjoy? ___

How often do you exercise? ___

What is the level of intensity of your physical activity? ___

Are your physical activities restricted for any medical reasons? ___

Any hobbies? ___

How many hours per week do you spend watching television? ___

How many hours per week do you spend on the computer outside of work? ___

22. Immunization History

Please list any immunizations that you have received recently (e.g., tetanus, PneumoVax, hepatitis, influenza, Gardasil, swine flu vaccine).

Date_Immunization_Adverse_reactions?

___

Have you had significant local or systemic adverse reactions to any of these (e.g., severe pain, swelling, or redness at the injection site; fever? ___

Do you feel that your health status has changed since receiving an immunization as a child or as an adult? ___

Have you ever received any of the following vaccines? Varicella (chickenpox) ___, Gardasil (HPV) ___, Hepatitis B ___, Influenza (flu shot) ___, Rotella virus ___, Polio ___, MMR (mumps, measles, rubella) ___, anthrax ___, PneumoVax (pneumococcal pneumonia) ___, Rabies ___, dT (tetanus shot) ___, DPT (diphtheria, pertussis, tetanus) ___

23. Toxic and Chemical Exposures

Do you live in a home where the basement has a leak or has flooded and not been repaired? ___

Any exposure to mold ___ , pet dander ___ , dust ___ , dust mites ___ , cleaning solutions ___ , work related toxins ___ , pesticides ___ , herbicides ___

Do you use an air filter/air purifier? ___ Which brand/technology? ___

Do you drink tap water? ___ Is your drinking water fluoridated? ___

Do you filter your water? ___ What type of filter (brand/technology) do you use? ___

Do you receive fluoride dental treatments? ___

Do you use fluoride containing toothpaste? ___ Brand of toothpaste: ___

Have you ever had mercury amalgams removed? ___

Have you ever had hydrocolon therapy or other detoxification therapy? ___

Have you ever had chelation therapy? ___

Do you use make up? ___ Type/brand: ___

Do you use hair care products? ___ Type/brand: ___

Do you use skin care products? ___ Type/brand: ___

Do you use feminine hygiene products (e.g., douche, spray)? ___

Have you ever had a laboratory assessment (blood, urine, stool, hair) for heavy metals or other toxins? ___

24. Basal Body Temperature – Instructions

1. Place a basal thermometer at your bedside the night before. If you use a glass thermometer, make sure you shake it down before going to bed.

2. Upon awakening, place the thermometer snugly in your armpit for a period of 10 minutes. You must not get out of bed before checking your temperature or you will have an altered reading. Try to take the temperature at as close to the same time each day as possible.

You may need to set an alarm to be accurate. It is best to use your basal thermometer after 5 hours of uninterrupted sleep. The minimum is 3 hours.

3. For women who are menstruating, the temperature should be taken starting on the second day of menstruation. However, if your medical appointment is scheduled before your next period check your temperature now and repeat it later on the second day of menstruation. For men and postmenopausal women, it makes no difference which day of the month the temperatures are taken.

4. The normal range is from 97.8 to 98.2 degrees Fahrenheit.

5. Log the basal body temperature:

• A basal thermometer is an ultra sensitive thermometer that measures temperatures by tenths of a degree. There are various kinds of basal thermometers available but a digital basal thermometer is best.

• A basal thermometer is more reliable and accurate than a simple glass thermometer since glass thermometers are only accurate to .2 degrees Fahrenheit.

• The main advantage of the digital basal body thermometer over a fever measuring body thermometer is speed.

© Copyright 2009 Fred Bloem, M.D. Updated: 08/27/09, 11:43 AM.

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