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Grainne McKeown, L.Ac, MSOMMindful Medicine WorldwideDate: ______________Name: ___________________________ DOB ___/ ___/____ Sex: M F Address: ___________________________________ City ___________________ State: ____ Zip: __________Mobile Phone: __________________Email ____________________________________________Home Phone: _____________ Business Phone: _____________ Emergency Contact: _____________________Occupation: ___________________ Height: _________ Weight: _________lbs.Name of your Physician: __________________________________________Who referred you to this office? _____________________________________1. What brought you here today? _______________________________________________________________________________________________________________________________________________________________________________________________2. When did you first notice any problems related to what brought you here today and what symptoms did you notice? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. What happened since you first noticed any symptoms and up to today?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. What previous medical workups, diagnosis and treatment have you had for this issue? How have these been helpful or unhelpful?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. Please list any allergies to drugs or medications:___________________________________________________________________________________________________________________6. What medications or supplements are you currently taking?Medication Dose How long have you been taking it?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7. Other illnesses, surgeries, injuriesIllnessesYear Illness Treatment/ medications _______ ________________ ________________________________________ __________________________ ________________ ________________________________________ ___________________ _______ ________________ ________________________________________ ___________________SurgeriesYear Surgery Outcome_______ __________________________________ ________________________________________________ __________________________________ _________________________________________Injuries / TraumaYear Injury / Trauma Treatment Outcome_______ ________________ ________________________________________ ____________________ _______ ________________ ________________________________________ ____________________ Menstrual CycleDays in a Full cycle (Ex. 28, 32, etc) ____________Days of bleeding _______________In general your periods tend to be (circle one) HeavyLightMediumDo you see clots in your menses? Yes NoDo you experience pre-menstrual symptoms? If so, please describe type, severity, time of occurance, duration, and what makes it better or worse. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. Family history (circle)Allergies Diabetes Emotional Difficulties Glaucoma Heart Problems Stroke Cancer Seizure Disorders Thyroid Problems Tuberculosis Hypertension/ High BP9. Do you have a pace maker? Yes NoPlease check any issues or symptoms that you presently have or have had in the past: Presently Had in Have Past Present PastCough??____Pneumonia____Cough with blood____Sputum/phlegm____Shortness of breath____Asthma____Bronchitis____Lack of perspiration____Seasonal allergies____Excessive perspiration____Chronic colds____Nasal or sinus congestion____Nose bleeds____Sinus infections____Nasal polyps____Loss of smell____Irregular heartbeat____Chest pains____Poor circulation____Heart attack____Dizziness____Low blood pressure____Palpitations____* High blood pressure____Fainting spells____* treatment _____________________Present Past Present PastIndigestion____Abdominal cramping____Nausea____Diarrhea____Vomiting____Constipation____Vomiting with blood____* Laxative use____Gas____* Product ______________________Bloating____Alternating diarrhea and constipation____Belching____Rectal pain____Acid regurgitation____Hemorrhoids____Poor appetite____Blood in stool____Excessive appetite __ __ Bowel movements every ______ days ______ number of bowel movements / dayFrequent urination____Burning on urination____Excessive urination____Difficulty urinating____Nighttime urination____Painful urination____Unable to hold urine____Blood in urine____Kidney stones____Sexually transmitted diseases____Bladder infections____Muscle pain____* Joint pain____Muscle weakness____* Where ___________________________ Muscle spasms____Neck pain____Back pain (lower)____Knee pain____Back pain (middle)____* Numbness____Back pain (upper)____* Where ___________________________Pain goes down the legs____Wear glasses____Eye tiredness / strain____Blurred vision____Seeing spots____Double vision____Sensitivity to light____Cataracts____Eye dryness____Glaucoma____Eye redness____Eyes feel swollen____Eye itchiness____Pressure in the eye____Eye tearing____Eye pain____Hearing difficulties____Loss of balance____Ringing in the ears____Ear infections____Ear pain____Sore throats____Sore gums____Mouth dryness____Bleeding gums____Bad taste in the mouth____Sore tongue____Bad breath____Numbness in the tongue____Mouth sores / ulcerations____Grinding teeth____Changes in the skin color____Dandruff____Skin easily bruising____Eczema____Present PastPresent PastSkin rashes____Psoriasis____Skin acne____Skin ulcerations____Body hair changes____Sudden weight loss____Sudden weight gain____Diabetes____Thyroid disorder____Anxiety____Problems with alcohol or drug use____Depression____Psychological crisis____Irritability____Psychoactive medications____Hot tempered____ if yes which ones ________________________Stress____Emotional difficulties____Fevers____Seizures____Chills____Concussion____Cold intolerance____Headache____General chilliness____Shaking / tremors____Cold hands / feet____Cysts / tumors____Heat intolerance____Edema / water detention____General warmth____Night sweating____Fatigue____Insomnia____Anemia____Nightmares____Poor memory____Smoking: How much per day/week? _______________________________________________________________Alcohol: How much per day/week? ________________________________________________________________NutritionWhat do you typically eat for the following:Breakfast: ________________________________________________________________________________Lunch: ___________________________________________________________________________________Dinner: __________________________________________________________________________________ExerciseWhat is your daily activity level related to your occupation:__Sedentary i.e mostly sitting __somewhat active__moderately active __very active (moving around or up most of the time)__heavy duty (lifting, moving thingd etc.)What kind of physical activity (exercise, sports) do you participate in? How often per week? How long each time?____________________________________________________________________________________________________________________________________________________________________________________Miscellaneous:How much water do you drink per day? __________________________________________________________How many caffeine containing products (coffee, tea, carbonated pop) do you drink per day? ________________ __________________________________________________________________________________________Snacks: ___________________________________________________________________________________Male Patients: Please fill out the following sectionPlease check any conditions or symptoms that you presently have or had in the past Presently Had in Presently Had in Have Past Have PastProstate enlargement __ __Premature ejaculation____Prostatitis____Impotence____Female Patients: Please fill the following sectionPregnancy: Are you presently pregnant? Y N Not surePlease list history of pregnancy, note if full term (FT), premature (P), miscarriage (MC), abortions (A), whether vaginal (V) or Cesarean section (C). Note any difficulties you experienced during the pregnancy and/or after delivery (for example morning sickness, edema, prolonged bleeding after delivery, gestational diabetes, high blood pressure, fever postpartum etc.)Year_______ ______________________________________________________________________________ _____________________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________MenstruationAge of onset _____ Last Menstrual Period (first day of) ____________ Date of last Pap exam ___/___/__Result ______________________ Length between periods ________________________________________Regularity:__ regular __ irregular __ usually early __usually late __ varies between by ____days by ____ days being early or lateHow many days of menstrual flow do you usually have? ________Flow is: __even __ uneven __ heavy __lightColor is: __ pale __ pink __ light red __ red __deep red __purplish __ brownConsistency is: __ thin __ thick __ clotted __dry and stickyDiscomfort with period:__ lower abdominal distention __before__during__ after menstruation__ lower back soreness__ before __ during__ after menstruation__ cramping __ before __ during __after menstruation__ Other_____________________________________________________________________________Premenstrual Syndrome (PMS)__irritability __bloating __mood swings __breast tenderness__ other _________________________________________________________________________________Vaginal Discharge __ No __Yes If yes, color , time in cycle and amount:__________________________________________________Menopause:Age of onset __________ Any difficulties / symptoms? ___________________________________________Uterine bleeding (not related to periods) Color _______________________ amount _______________________comes on suddenly __ all the time ................
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