Comprehensive Health History - Deborah Barbiere, Psy.D., L.Ac.
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Deborah Barbiere, Psy.D., L.Ac. Integrative Health NYC 12 West 9th Street, Suite 1B-1 212.620.7076 COMPREHENSIVE PSYCHOSOCIAL/HEALTH HISTORY First Name: Middle Initial: Last Name: Date of Birth: Address: City/State/Zip: Email Address: Cell Phone: Home Phone: Work Phone: Occupation: In Case of Emergency Contact: Relationship & Phone: I am seeking services in (please circle all that apply): Psychotherapy/Biofeedback/Life Coaching/EFT/Acupuncture/Herbal Medicine I am interested in learning more about (please circle all that apply): Psychotherapy/Biofeedback/Life Coaching/EFT/Acupuncture/Herbal Medicine Relevant Physicians/Specialists/Practitioners: Name____________________Address________________________________Phone________________ Name____________________Address________________________________Phone________________ Name____________________Address________________________________Phone________________ * I _____________________ hereby grant Dr. Deborah Barbiere permission to provide and obtain information regarding my medical and psychological condition, progress and treatment from the providers listed above. Signature_________________________________________________ Date______________________ Reason for Today’s Visit: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ How, when & where did this condition begin? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What other forms of treatment have you sought? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please list any other psychological/emotional/behavioral/health issues you’d like to address in order of importance (ex. insomnia, headaches/migraines, weight loss, digestive issues, acne, drug use, etc) 1. _____________________________________ 2. _____________________________________ 3. _____________________________________ Your Medical History: Surgeries, Major Illnesses, Hospitalizations, and Major Accidents: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Current Medications, Supplements, and Vitamins (and what theyr are for): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ SOCIAL/BEHAVIORAL HISTORY Tobacco Use Cigarettes: ____Never _____Quit (date_______) _____Current Smoker (packs/day_____ # of years____) Other Tobacco: _____Pipe _____Cigar _____Snuff _____Chew Are you interested in quitting? YES/NO Alcohol Use Do you drink alcohol? YES/NO # of drinks/week________ Is your alcohol use a concern for you or others? YES/NO Drug Use Do you use any recreational drugs? YES/NO Have you ever used needles to inject drugs? YES/NO Sexual Activity Sexually active: YES/NO/NOT CURRENTLY Current sex partner(s) is/are: MALE/FEMALE Birth control method:___________________ Have you ever had any sexually transmitted diseases (STDs)? YES/NO Caffeine Intake: _____None _____Coffee/Tea/Soda ( ______cups/day) Weight: Are you satisfied with your weight? YES/NO Diet: How do you rate your diet? GOOD/FAIR/POOR Do you take any dietary supplements? YES/NO (please explain) ___________________________________________________________________________ Exercise: Do you exercise regularly? YES/NO What kind of exercise?_________________________________________________________ How long (minutes)?_______________________ How often?_________________________ If you do not exercise, why?_____________________________________________________ Safety: Is violence at home a concern for you?____________________________________________ Have you ever been abused?____________________________________________________ How do you FEEL about the following areas of your life? Please circle any of these areas you’d like to address in your treatment. Great Good Fair Poor Bad Problems you may be experiencing Significant other Family Diet Sex Self Work Exercise Spirituality ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____________________________________________ ___________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ If you are interested in EASTERN MEDICINE MODALITIES (Acupuncture, Herbal Medicine, etc), or would like to know how these treatments may apply to you, please complete the next pages: Body Systems Review (please check all that apply) 0=never 1=in the past but not now 2=occasionally 3=frequently 4=almost always 01234 01234 01234 01234 01234 01234 01234 low or excessive appetite loose stools abdominal gas/bloating after food fatigue after eating organ prolapsed bruise easily obsessive thoughts/worrying 01234 01234 01234 01234 01234 01234 01234 heavy limbs fatigue hemorrhoids belching nausea diarrhea craving for sweets 01234 01234 01234 01234 01234 01234 spontaneous sweat allergies asthma shortness of breath cough dry nose/mouth/skin/throat 01234 01234 01234 01234 01234 01234 feeling of sadness catch colds easily feel tired after exercise general weakness nasal discharge sinus congestion 01234 01234 01234 01234 01234 01234 01234 sore, cold or weak knees low back pain frequent urination urinary incontinence ear problems early morning diarrhea craving salt 0 1 2 3 4 feeling cold 0 1 2 3 4 edema 0 1 2 3 4 hair loss 0 1 2 3 4 memory loss 0 1 2 3 4 hot flashes 0 1 2 3 4 nightsweats please circle: high low normal libido 01234 01234 01234 01234 01234 01234 01234 01234 01234 01234 irritable feel better after exercise tight feeling in chest alternating diarrhea/constipation symptoms worse with stress neck/shoulder tension floaters in vision brittle or weak nails feeling of heat rushing to head difficulty making plans or decisions 01234 01234 01234 01234 01234 01234 01234 01234 01234 01234 muscle spasms/twitches heartburn/acid reflux dry eyes/red eyes ear ringing anger easily sand in eyes hair loss frequent headaches blurry vision gall stones 01234 01234 01234 01234 01234 01234 feel heart beating insomnia sores on tip of tongue anxiety restlessness red cheeks 01234 01234 01234 01234 01234 01234 chest pain disturbing dreams excessive laughter palpitations excessive sweat nightmares Continue to next page Urination (please circle all that apply): Burning Scanty Cloudy Urgent Profuse Dark Bowel Movements: Frequency_____________________ Feels Complete? Yes Consistency: Well-formed In stools? Undigested food Are you thirsty? Yes Retention Dribbling Pale Frequent When? ______________ No No Hard Loose Blood Alternates Mucus If so do you crave warm or cold drinks? ___________________ Do you find that you “run” particularly hot or cold? ___________________________________________ How is your energy in general? ___________________________________________________________ Do you often get headaches or migraines? Yes No If yes where do you feel the pain? _________________________________________________________ Are they dull and aching OR sharp and stabbing in nature? _____________________________________ When do you normally get them? _________________________________________________________ How do you feel emotionally right now? ____________________________________________________ Describe what you eat: __________________________________________________________________ Sleep: Hours per night __________ Time to bed __________ Time to rise _____________ Rested in AM? Yes No Trouble falling asleep? Yes No Sometimes Waking up at night? Yes No Get up to urinate more than once? Yes No Work: Enjoy work? Yes No Continue to next page Hours per week working _________ For Women: Age of 1st period______________ Are you pregnant? Y/N # of pregnancies________ Age of last period (menopause) ___ # of: live births___ abortions___ miscarriages___ # of Days between periods___ Date of last: Gyn exam________ Pap Smear_________ # of Days of flow___ Mammogram________ Bone Density Scan_________ Color of flow_____________ Results:______________________________________ Clots? Y/N Color________ _______________________________________ Have you been diagnosed with: ___Fibroids ___Fibrocystic Breasts ___Endometriosis ___ Ovarian cysts ___PID Other_____________________________________________ Location of pain: ___Lower abdomen ___Lower Back ___Thighs ___Other_______ Nature of Pain (please indicate before, during or after menses) Cramping_______ Stabbing_______ Burning________ Aching________ Dull_________ Bloating________ Consistent________ Intermittent________ Bearing Down__________ Other symptoms related to menses: ___ discharge ___ nausea ___ swollen breasts ___ poor appetite ___ increased libido ___ vaginal dryness ___ constipation ___ mood swings ___ hot flashes ___ decreased libido ___ headache ___ diarrhea ___ ravenous appetite ___ night sweats ___ insomnia For Men: Date of last prostate check up_____ PSA results __________ Manual exam results____________ Lab results______________________________________________________________________ Frequency of Urination: day____ night_____ Color of urine: __clear __murky Odor:________ Symptoms related to prostate: ___ prostate problems ___ back pain ___ delayed stream ___ increased libido ___ groin pain ___ dribbling ___ decreased libido ___ testicular pain ___ incontinence ___ premature ejaculation ___ retention of urine ___ impotence THANK YOU, WE LOOK FORWARD TO YOUR VISIT!
