www.homeopathyphysician.com email homeopathicdrpal@yahoo.com NEW PATIENT HISTORY FORM To our new patients: To help us establish you with our Homeopathic practice, please provide us with your complete health history including all Physical and Mental symptoms. Date -______________ Personal History Name: ________________________________________ Date of Birth____/____/______(mm/dd/yyyy) Age____________ Occupation ______________________ Birthplace___________________________( City & Country ) Height__________________inches Weight____________________( lbs or Kg ) Referred by:___________________________ Preferred Language for consultation –1st____________________2nd____________________( English, Hindi, Urdu, Punjabi ) ALLERGIES: Like – Food, Pollens, Odors, Medicines, Pets etc… _________________________________________________________________________________________ _________________________________________________________________________________________ _______________________________________________________________________ MAIN PROBLEMS/ REASONS FOR THIS CONSULTATION: (if possible, rank in terms of importance to you) 1. _______________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________ Additional problems or concerns you would like to be addressed: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ____________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _____________________*Note: we may not be able to address every problem during the course of one treatment. Current Medications ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Current Herbs / Vitamins/ Homeopathy/ Supplements ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Dose _________ _________ _________ _________ _________ Dose _________ _________ _________ _________ _________ Times / Day ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ Times / Day ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ PAST MEDICAL, SURGICAL & TRAUMA HISTORY Patient Name: List prior illness, injury, hospitalization, surgery, and/or trauma: Reason: Date/Month and Year _________________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________________________ PERSONAL AND FAMILY HISTORY Check those that apply: Yourself AIDS Alcoholism Allergies Alzheimer’s Anemia Arthritis Asthma Birth Defects Bleeding Disorder Breast Cancer Cancer Colon Cancer COPD Depression Diabetes Emphysema Epilepsy Glaucoma Heart Attack Heart Trouble High Blood Pressure IBS Kidney Disease Liver Disease Mental Illness Migraine Headaches Pneumonia Prostate Cancer Sickle Cell Anemia Stroke Suicide Tuberculosis Ulcers Other Mother Father Grandparents Sister/ Brother Spouse Children SOCIAL HISTORY (check those that apply): Patient Name: Marital status: Education level completed: Memories of your childhood Do You Find Your Life single high school Mostly happy Generally Unsatisfactory married college Mostly painful Too Demanding divorced professional school Normal Boring Widowed other: don’t recall Satisfactory Living arrangement: alone family roommate significant other children (list sex/ages):_________________________________________ Major stresses in last 2 years Money Job Marriage Home Life Children other stress___________________________________________________________________________________________ Pertinent travel history:(out of USA, epidemic areas) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ LIFESTYLE / SELF-CARE ISSUES Do you smoke cigarettes? Did you ever smoke? Do you drink alcohol? Do you drink caffeine beverages? Do you use recreational drugs? Do you manage stress well? Do you exercise regularly? Do you enjoy your job? Do you allow time to unwind and relax? Do you sleep soundly? Are you satisfied with your sex life? Are you satisfied with your social life? Are you satisfied with your spiritual life? Is your diet healthy enough? YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO If yes, how many? #_____yrs. ______________ packs per day If yes, when did you quit? ______________ If yes, how much? Type_________ & _________ drinks per week If yes, which? ________________________________________ If yes, which? _________________________________________ NOT SURE NEED HELP If no, why? _________________________________________ If no, why? _________________________________________ If no, why? _________________________________________ If no, why? _________________________________________ If no, why? _________________________________________ If no, why? _________________________________________ If no, why? _________________________________________ NOT SURE NEED HELP Typical breakfast___________________________________________________________________________________________________ Typical lunch _______________________________________________________________________________________________ Typical dinner_______________________________________________________________________________________________ Typical snacks_______________________________________________________________________________________________ Devices Do You Use: ___Eyeglasses ___Brace (Neck, Back) ______Contact Lens ______ Pacemaker ______Hearing Aid ______ IUD, Diaphragm ______Dentures ______Artificial Limbs REVIEW OF SYSTEMS Check any symptoms that currently apply to you: Constitutional Mouth, Throat ___ poor appetite ___ fevers ___ chills ___ food craving ___ weight loss ___ weight gain ___ fatigue Eyes ___ tongue discoloration ___ bad breath ___ teeth problems ___ grinding teeth ___ tonsillitis/ adenoids ___ facial pain ___ sore throat ___ ulceration tongue ___ gum bleeding ___ eye pain ___ blurred vision Heart & Circulation ___ poor vision___day ____chest pain ___ poor vision___night ____ lightheadedness ___ wear corrective lenses ___ palpitations ___ near____far sighted ____ cold hands/feet ___ other ____ fainting Ears, Nose ____ swelling feet ___ ringing ears ____ blood clots ___ nosebleed/polyp ____ varicose veins ___postnasal drip Breathing & Lungs ___sinus problems _____shortness of breath ___trouble with taste/smell _____wheezing or asthma ___poor hearing _____repeated colds/ flu ___earaches/ infections _____ cough dry/ irritating ___sneezing/ discharges Immune System ____too many infections ____allergies to food ____allergies to environment ___ other concerns Blood System ____lymph gland swelling ____anemia ____easy bruising Mind Symptoms ____memory ____temper/anger ____emotional ____sleep Sexual Organs ____ sores on genitals ____ lumps or swelling ____ erection problems ____ premature ejaculation ____pain with sex ____infertility ____repeated infections ____aversion to sex Thermal State ___hot ___chilly Patient Name: Muscles, Bones & Joints Digestion & Intestines ____neck pain ____back pain ____muscle pain ____ painful joints: R__L__ ____shoulder ____elbow ____hip____ knee ___ankle ____wrist _____fingers ____joint swelling ____muscle weakness ____muscle cramps ____indigestion ____belching/ flatulence ____difficulty swallowing ____heartburn/ ulcer ____nausea ____ liver trouble ____ vomiting ____ diarrhea ____ cramping bowels ____ food allergies ____constipation ____ abdominal pain ____rectal pain/ itching ____ hemorrhoids/ piles ____ blood in stool Skin, Hair ____ psoriasis ____ warts ____ freckles ____ itching, hives ____ hair loss ____ dry skin, eczema Nerves, Movement, Brain ____ seizures _____nerve pain _____poor balance _____poor coordination _____tremors or shaking _____headaches Urine, Kidney, Bladder ____painful urination ____wake up to urinate ____kidney stones ____ loss of control ____ frequent urination ____ sudden urging ____ blood/pus urine ____urine infection UTI Women Reproductive _____ pelvic pain _____ vaginal discharge _____ painful periods _____premenstrual syndrome _____ hot flashes _____ itching or soreness _____irregular menses _____leucorrhoea ____age period started ____ # of pregnancies ____# abortions ____# miscarriages ____# live births ___children currently living ___age menopause ___ ___past infertility Additional Symptoms -___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ IF NOT NOTED IT IS EITHER NEGATIVE, NON-CONTRIBUTORY, AND/ OR NON-PERTINENT. HEALTH SCREENING HISTORY List the date of your most recent test or exam. Patient Name: Mammogram _________ Pap Smear__________ Self Breast Exam ___________Breast Exam by Doctor____________ Blood test for Cholesterol _________ Blood Sugar ________Other Blood tests__________________________________ Immunizations: Tetanus_______________Hepatitis______________MMR____________________Flu Shot_____________________ Test for Blood in stool_______ Rectal Exam ______________Feeling the Prostate_________ Scope Lower Bowel_______________ Self Exam Testicle ___________Testicle Exam by Professional____________ Anatomy\Procedure Back Brain Chest Colon Extremities (Arm/ Leg) Gallbladder Kidney Neck Pelvis Stomach Other X-ray MRI CT Scan Ultrasound >>Copies of reports should be sent with the patient form Bone Scan Mailing Address -- >>Pictures should be sent with the patient form EKG EEG PAL 14534 GRAHAM AVE VICTORVILLE, CA USA 92394 This history record has been designed to facilitate our patients to assess their health issues in detail. Once Homeopath Pal Looks over this history record and reports he will be asking you specific questions pertaining to your symptoms to get a complete disease picture. Each symptom will be completed regarding its location, extension, sensation, modalities and concomitants during the virtual consultation process. A complete case record thus created will be analyzed for a Homeopathic prescription. This is a confidential record and will be kept in the office. Information contained here will not be released to anyone without your authorization to do so. _____________________________________________________ Date Patient/ Guardian signature that filled out the history Mailing Address ___________________________________________________ Phone – Home -- ___________________________ Cell -- ___________________________ Email -- ___________________________ ___________________________________________________ ___________________________________________________ For more information visit www.homeopathyphysician.com see virtual consultation tutorial