Deborah Buckwalter



Health History

Name __________________________________________________________________ Today’s Date _________________

Age _______ Birthdate ______________ Highest level of education: ______________ Handedness: Right Left Ambidex

Date of most recent medical visit ________________ Why were you seen? _____________________________________

Main reason for visit ___________________________________________________________________________________

Your answers on this form will help your health care provider better understand your medical history, concerns and symptoms. If you are uncomfortable with any question, do not answer it.

How would you rate your general health currently? __ Excellent __ Good __ Fair __ Poor

SYMPTOMS: Please Check Symptoms You currently have or have had in the past year

GENERAL

Low mood

Withdrawal

Crying

Suicidal thoughts

No motivation

Weight loss? gain?

Appetite: More/Less

Sleep: More/Less

Headaches

Anxiety

Panic attacks

Fatigue easily

Low energy

Sweats

Forgetfulness

Memory loss

Anger

Other ______________

Cardiovascular

Chest pain/discomfort

Palpitations

Irregular heart beat

Blood pressure: Hi/Lo

Stroke

Diagnoses: __________ Other ______________

Eyes

Vision difficulties R/L

Blurred vision R/L

Visual flashes R/L

Visual halos R/L

Swelling of eyes R/L

Diagnoses: __________

Other: ______________

Respiratory

Cough Wheeze

Allergies Congestion

Bronchitis Asthma

COPD

Diagnoses: __________

Other ______________

Musculo-skeletal

Muscle pain/tension

Arthritis

Pain/Weakness in:

Joints

Neck

Shoulder R/L

Upper Back R/L

Mid Back R/L

Lower Back R/L

Hip R/L

Knee R/L

Ankle R/L

Foot R/L

Diagnoses: __________

Other: ______________

neurological

Dizziness/fainting

Weakness

Numbness

Nerve Pain

Slurred speech

Spasm

Myoclonus (twitches/jerks)

Diagnoses: __________

Other: ______________

Ear/Nose/Throat

Difficulty hearing

Ringing in ears

Vertigo

Difficulty swallowing

Diagnoses: __________

Other ______________

SKIN

Rashes Eczema

Psoriasis Rosacea

Skin Cancer

Cold or canker sores

Herpes

Pigmentation changes

Cellulitis

Diagnoses: __________

Other: ______________

Gastrointestinal

Overeating

Eating disorder

Heartburn/reflux

Nausea/Indigestion

Vomiting

Bowel problems

IBS

Bloating

Diagnoses: __________

Other ______________

Genitourinary

Urination difficulty:

Frequent Painful

Blood in urine

Leaking urine (mild)

Urinary incontinence

Diagnoses: __________

Sexual functioning

Low/No libido

High libido

Identity concerns

Arousal difficulty

Orgasm difficulty

Sexual addiction

Painful intercourse

Diagnoses: __________

Other ______________

Male reproductive

Hormonal problems

Erectile dysfunction

Ejaculation concerns

Testicular problems

Low sperm count

Lump: breast/penis

Andropause

Diagnoses: __________

Other: ______________

Female reproductive

Hormonal problems

PMS

Pregnancy concerns

Miscarriage

Menopause:

Pre Peri Post

Perimenopausal Sx

Breast Concerns

Diagnoses: _________

Other: ______________

Other health conditions, concerns, or diagnoses:

CURRENT MEDICATIONS: Prescription and non-prescription medicines, supplements, etc.

______________________________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Any medication or drug concerns: __________________________________________________________________________

Prescribing Physician(s): __________________________________________________________________________________

_______________________________________________________________________________________________________

CONDITIONS: Please check conditions you have or have had ANY TIME IN THE PAST

o Acid Reflux

o Acne

o Addiction

o Alcoholism

o Allergies

o Anemia

o Anxiety

o Attention Deficit Disorder

o Alzheimer’s disease

o Anorexia

o Arthritis

o Asperger’s Syndrome

o Asthma

o Autism

o Autoimmune disorder

o Bedwetting

o Bipolar Disorder

o Bladder problems

o Bleeding disorder

o Blood pressure issues

o Bone fracture

o Borderline Personality

o Brain disease

o Brain injury

o Brain tumor

o Breast cancer

o Bronchitis

o Bulimia

o Burns

o Cancer ____________

o Carpal Tunnel

o Cataracts

o Celiac disease

o Chicken pox

o Cholesterol-high

o Chronic pain

o Clumsiness

o COPD

o Colon problems

o Concussion (# )

o Crohn’s disease

o Deep vein thrombosis

o Dependent personality

o Depression

o Diabetes

o Disability (type)

o Dyslexia

o Elective surgery

o Endometriosis

o Epilepsy

o Erectile Dysfunction

o Exposure to toxic mold

o Exposure to toxic chemicals

o Fertility issues

o Fibromyalgia

o Genetic disorder

o Gynecological problems

o Headache

o Hearing loss

o Heart attack

o Heart disease

o Hemorrhage

o Hepatitis

o Hernia

o Herniated disc

o Herpes

o HIV/AIDS

o Hormone imbalance

o Incontinence

o Infertility

o Irritable Bowel

o Kidney disease

o Learning Disability

o Liver disease

o Lung disease

o Lupus

o Mania

o Measles

o Memory issues

o Menopause

o Migraine

o Miscarriage

o Mononucleosis

o Mood disorder

o Multiple Personality

o Multiple Sclerosis

o Mumps

o Narcissistic personality

o Near-drowning

o Obesity

o Obsessive-Compulsive

o Orthopedic difficulties

o Osteoporosis

o Pacemaker

o Panic attack

o Paranoid Personality

o Parkinson’s

o Phobias

o Polio

o Pneumonia

o PTSD

o Premature birth

o PMS

o Prostate issues

o Psoriasis

o Restless Leg Syndrome

o Rosacea

o Scars

o Sciatica

o Schizoid personality

o Schizophrenia

o Seizures

o Sensory sensitivity

o Sleep disorder

o Sleep apnea

o Smallpox

o Snoring

o Social Anxiety

o Sports injury

o Stomach problems

o Stroke

o Suicide attempt

(# ____)

o Surgical termination of pregnancy

o Thyroid problems

o Trauma

( ) Childhood

( ) Adult

o Tuberculosis

o Ulcers

o Urinary tract infection

o Varicose veins

o Vertigo

o Other Conditions: (List)

o ____________________________

o ____________________________

o ____________________________

o

SURGICAL/HOSPITALIZATI0N HISTORY: Please list serious illnesses, injuries, surgeries/procedures:

|Illness/Injury-------------------- |Hospitalized |Surgery/Procedure |Year |Residual effects/problems |

| |Yes No | | | |

| |Yes No | | | |

| |Yes No | | | |

| |Yes No | | | |

Psychiatric History: Please note history of mental health difficulties (e.g. Depression, Anxiety, Bipolar Disorder, Personality Disorder, or other Mental health diagnoses).

|Mental Health |Age of Onset |Treatment (therapy, medication, |Outcome |Additional Information |

|Difficulty/Diagnosis | |hospitalized, etc) | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

CURRENT HABITS

Do you currently exercise? No Occasionally 2-5 days per week Daily

How would you characterize your diet? Very Healthy Mostly healthy Fair Poor

Do you currently smoke or use any tobacco products?

Yes #/day: _____

No

Quit #/day:_____ for how long? _________ Date quit: _________________

Do you currently use any form of cannabis/marijuana?

Yes How frequently : ______________ How Long: _________

No

Quit Previous frequency:_____ Duration: _________

Do you currently use any other non-prescribed drugs?

Yes #/day: _____

No

What drugs have you experimented (brief use) with? List them all: ____________________________________

What drugs have you used with regularity? ________________________________________________________

At what age did you start? _______ If you quit, how long ago was it? _________________

Do you currently drink alcohol?

Yes #/week: _____ Alcohol of choice: _____________

No

Quit #/week:_____ for how long? _________

Have you ever felt you should cut down on your drinking? _____________________________________________

Has anyone close to you ever felt you should cut down on your drinking? _________________________________

Do you practice Meditation or Mindfulness? No Occasionally Regularly

Anything else you would like to say about your health habits, present or past? ______________________________________

FAMILY HISTORY: Please fill in information about your family of origin (use back of page if more family members)

|Relation to you |Age |How would you characterize your |Health Issues |Psychological & |Alcohol / Drug |

| |(D if deceased|relationship with this person? |(Past and present) |Psychiatric problems |use/abuse |

| |and what year)|(good, fair, poor…) |or cause of death |(Past and present) |(Check () |

|Mother | | | | | |

|Father | | | | | |

|Step-Mother | | | | | |

|Step-Father | | | | | |

|Brothers | | | | | |

|Check (() if | | | | | |

|half-sibling | | | | | |

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|Sisters | | | | | |

|Check (() if | | | | | |

|half-sibling | | | | | |

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CURRENT (Nuclear) FAMILY HISTORY:

|Relation to you |Age |How would you characterize your |Health Issues |Psychological & |Alcohol / Drug |

| |(D if deceased|relationship with this person? |(Past and present) |Psychiatric problems |use/abuse |

| |and what year)|(good, fair, poor…) |or cause of death |(Past and present) |(Check () |

|Spouse name | | | | | |

|Partner name | | | | | |

|Other name | | | | | |

|Children | | | | | |

|If not biological | | | | | |

|note if | | | | | |

|Adopted- A | | | | | |

|Step- S | | | | | |

|Foster- F | | | | | |

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Is there anything ELSE you feel is important for Dr. Buckwalter to know about you or about your concerns regarding your physical or mental health? If so, please describe:

what would you say your strengths are?

what are you currently doing to manage your challenges and difficulties (if any)?

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