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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