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Golden+Yogi+Health+Assessment+Form Doc-2
Golden+Yogi+Health+Assessment+Form Doc-2
Golden+Yogi+Health+Assessment+Form Doc-2
ADULT
● Please complete this form prior to your visit. Bring it with you the day of your visit. Please do not mail it!
● This questionnaire is an important part of your visit. Accurate completion of this form will assure that you
receive the best possible care in the time set aside for your visit.
● Please allow up to 60-90 minutes to complete this form. Please do not wait until the night before your visit.
PERSONAL INFORMATION:
Name Age Sex Marital Status
I claim full financial responsibility for all services rendered at Golden Yogi. I understand that payment is required in full at the
time of service. I certify the information provided in this Health Assessment is correct to the best of my knowledge. I agree to
notify Golden Yogi of any changes with respect to the information provided in this form. I consent to medical evaluation and
treatment . I give permission to be contacted at the above numbers (including voicemail) for scheduling and office-patient
communication.
WHAT HABITS, ACTIVITIES, OR ATTITUDES DO YOU CONSIDER TO HAVE CONTRIBUTED TO ANY OF YOUR
PROBLEMS?
PAST HISTORY
Did your mother have any problems during pregnancy with you? (Stress, illness, smoking, medications, alcohol)
Other comments:
CHILDHOOD ILLNESSES
Colic Allergies Rheumatic fever German measles
PAST HISTORY
Using the Medical History category below please write down which apply to you in the box below:
MEDICAL HISTORY
Please circle if your family members including grandparents have ever had any of the following problems. Specify who.
Alcoholism Glandular fever
High cholesterol Rheumatic fever
Allergies Digestive disease
Asthma Rheumatoid disease
Eczema or psoriasis Herpes or shingles
Hayfever Sinus disease
Frequent infections Hypoglycemia
Anemia Strokes
Urinary infections Drug problems
Arthritis Thyroid problems
Lupus Tuberculosis
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Mental illness Heart disease
Depression Ulcers
Bleeding or bruising Hepatitis
Migraines High blood pressure
Cancer Weight problems
Pneumonia Comments:
Convulsions or epilepsy
Polio
Crohn’s disease or colitis
Prostate problems
Diabetes
ANTIBIOTICS
Have you ever been on frequent or prolonged antibiotics?
HOSPITALIZATIONS
List major hospitalizations. Please give dates, locations, diagnoses, lengths of hospital stays, and surgeries.
NON-PRESCRIBED MEDICATIONS
List any laxatives, antacid, aspirin, antihistamines, decongestants, stimulants, etc.
PRESCRIBED MEDICATIONS
Name of drug and dose (BP meds, Inhalers, painkillers, sleeping pills, anti-depressants, oral contraceptive pill, etc)
ALLERGIES TO MEDICATIONS
Name or types of drug and reaction:
LIFESTYLE:
Please be specific with your answers regarding types and quantities where requested
EXERCISE
Do you exercise regularly: Type(s) of exercise:
STRESS REDUCTION
Do you do any stress reduction or relaxation such as meditation, yoga, prayer, self-hypnosis, etc.?
What level of stress do you consider yourself to be under? Low Medium High
What factors do you think influences your stress?
SLEEP
How many hours per night: Is it restful or restless: What time do you retire:
SMOKING
Do you currently smoke? If yes how often:
Did you ever smoke? If yes how often and for what duration:
ALCOHOL
Specify what type of alcohol, amount and frequency
Do you drink to excess? Did you ever drink to excess? When did you stop?
NUTRITION
Please take the time to answer these questions specifically and concisely.
Specify what foods and beverages you normally consume during a typical day (Please be specific):
Snack
Lunch
Snack
Dinner
Snack
Do you eat regularly or irregularly: Do you binge or use food for rewards/escape:
What work or scheduling considerations might create difficulties for you in trying to change your eating and other health
habits?
WOMEN
Date last period began: Date of last pelvic exams:
Date prior period began: Age at first period:
Date of last pap smear: Were the results normal:
Have you ever had an abnormal pap: When:
Results: Treatment:
Are you sexually active: Do you practice safe sex:
Are you trying to get pregnant: How long have you been trying:
Current birth control method: How long?
Past birth control methods?
Normally (not on pills) the number of days from the start of one period to the start of the next?
Number of days of flow?
Any bleeding between periods: When:
Any unusual pelvic pain, sensations, pressure or fullness:
Any unusual vaginal discharge or itching:
How long: Past treatment:
Any sexual concerns to discuss:
Any past history of tubal infection:
Any past history of sexually transmitted disease (STD)?
Have you ever had herpes: Venereal warts or papilloma virus?
Number of pregnancies: Dates of pregnancies:
Have you had any Miscarriages:
Describe any infertility problems:
Have you ever breastfed:
Have you ever had breast lumps:
Do you ever have nipple discharge:
Other?
MENSTRUAL SYMPTOMS
Check P for premenstrual; Check D for during the menstrual period; Check A for after menstrual period
P D A SYMPTOM P D A SYMPTOM
Intermittent abdominal cramps Headaches
Constant cramps Sugar/ Food cravings
Low back pains Depression
Pressure sensations Irritability
Breast tenderness Acne
Mood swings Other:
How severe are the symptoms:
MEN
Male Reproductive
Libido / Sexual dysfunction
Impotence
Hernia
Prostate examination?
Testicular examination?
Digestive
Dental problems or decay
Sore/ bleeding gums or tongue
Loss of taste or smell
Sores in or around mouth
Difficulty swallowing (Dysphagia)
Recurring indigestion
Nausea or vomiting
Intestinal gas or flatulence
Belching / Reflux
Bloating
Abdominal pain or cramps
Constipation
Diarrhea or loose stools
Rectal itching
Haemorrhoids
Blood with stools
Pain with passing bowel motion
Black stools
Diverticulitis or diverticulosis
Loss of appetite
Constant hunger
Parasites
Traveller’s Diarrhea
Liver
Jaundice
Hepatitis or pancreatitis
Acid reflux
Endocrine
Feel excessively warm
Feel excessively cold
Weight loss/ gain
Diabetes
Low Blood Sugars
Night sweats
Hot Flashes
Fatigue/ constant low energy
Hypothyroid (low)
Hyperthyroid (high)
Urinary
Freq/Urgency
Colour (Brown or red urine)
Pain on urination
Blood in urine
Prostate Nocturia
Loin Pain
Diff. Start/stop or Incontinence
Kidney or bladder infection
Recurrent Urinary Tract Infections
Cardiovascular
Heart murmur
High blood pressure
Low Blood pressure
Skipped heartbeats
Racing heart
Chest pain or pressure
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Swollen feet or ankles (Oedema)
Difficulty breathing at night
Varicose veins
Respiratory
Sinus or nasal congestion
Runny nose
Frequent colds
Nasal polyps
Sore throats
Swollen glands
Recurrent fevers or chills
Shortness of breath
Wheezing or gasping
Coughing
Coughing blood
Chest colds or pneumonia
Immune
Frequent colds/coughs
Glandular Fever
Herpes/ Cold sores
Other recurrent infections
Nervous
Sleep (Onset/maintenance)
Headache
Migraine
Visual Disturbances
Dizziness/Vertigo
Blackouts or fainting
Loss of balance
Memory loss
Anxiety/nervousness
Stress
Depression
Suicidal thoughts
Sought psychological help
Epilepsy
Trembling or tremors
Musculoskeletal
Osteoporosis
Aching muscles or joints
Arthritis (Osteo / Rheum)
Joint stiffness
Back or neck pain
Weakness
Painful feet
Leg cramps
Injuries
Skin
Dry / Oily
Acne
Eczema
Psoriasis
Dandruff or seborrhea
Rashes / Itching or burning skin
Hives
Dermatitis
Fungal
Herpes – cold sores
Moles
Numbness or tingling
Easy bruising
Eyes / Sight
Blurry vision
Double vision
Cataracts
Eye pain or itching
Watering eyes or redness