Shenandoah Health Associates, LLC.
Virginia I. Hisghman, PhD, L.Ac.
157 Creekside Lane, Winchester, Virginia 22602
540-667-7007
www.healthyshen.com
MOTHER
FATHER
FAMILY HISTORY
BROTHERS
SISTERS
PARTNER
CHILDREN
Age
(age at death)
Current Health
(cause of death)
MARK AN INITIAL (M, F, B, S, Sp/P, C) FOR ALL CATEGORIES BELOW THAT ARE
APPLICABLE, PAST OR PRESENT: MOTHER , FATHER, BROTHERS, SISTERS,
SPOUSE/PARTNER, CHILDREN
____________Cancer _______________________Diabetes _________________Heart disease
____________Hi blood pressure _______________Stroke____________________Epilepsy
____________Mental illness __________________Asthma_____________________Allergies
____________Skin diseases __________________Anemia_________________Kidney disease
____________Glaucoma ___________________TB, HIV, HPV, Hep_____________Ulcer/colitis
______________Thyroid disease __________________Autoimmune Diseases (what?)
PATIENT HISTORY
HOSPITALIZATIONS AND SURGERIES (begin with the most recent; remember to include
hysterectomies, vasectomies, etc.):
ABNORMAL LAB TESTS, ultrasound, MRI, etc.:
ALLERGIES
Drugs ___________________________________________________________
Foods ___________________________________________________________
How were you tested? _______________________________________________
TYPICAL DIET
Breakfast
____________________________________________________________________________
Lunch
____________________________________________________________________________
Dinner
____________________________________________________________________________
Snacks
_____________________________________________________________________________
Cravings (sweet, salty, sour, bitter, spicy, other)
_____________________________________________________________________________
EXERCISE and HABITS (describe: type and amount; habits: alcohol, drugs, smoking, sweets,
cheese, etc.)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
LIFETIME REVIEW OF ILLNESSES (LIST, but DO NOT describe, all serious physical or
emotional complaints that you have suffered; begin with the most recent complaints):
Psychological/Emotional:
Musculoskeletal:
Skin:
Head (describe: pain, discomfort, discharge, include eyes, ears, nose, throat):
Lungs/Infections:
Heart and blood vessels:
Stomach and bowels:
Urinary/reproduction:
Communicable diseases (TB, Hepatitis, Sexually Transmitted Diseases, HIV, AIDS, other):
CURRENT HEALTH STATUS
CHIEF COMPLAINT (description, previous therapies):
WHEN DID IT START and DO YOU KNOW WHY?
WHAT MAKES IT BETTER AND WORSE? (ex: heat, cold, foods, pressure, bending, positioning)
WHAT IS THE QUALITY OR TYPE OF SENSATION OR PAIN (DESCRIBE)? (ex: achy, burning,
fixed, colicky, sharp, deep)
DOES IT RADIATE TO OTHER AREAS OF THE BODY? Y / N If yes, where? ______________
IS IT MILD OR SEVERE?_
IS IT CONSTANT OR INTERMITTENT?
OTHER COMPLAINTS:
MENTAL (how is your memory and concentration?)
EMOTIONAL (describe:are you happy with money, work, family? How is your emotional state?):
STRENGTH/IMMUNITY (describe: your energy level; do you get frequent colds and flus,
allergies?):
SLEEP (do you sleep well, easy to fall asleep, wake refreshed? Restless, dream disturbed?):
TEMPERATURE (prefer hot or cool weather; do you sweat easily; nightsweats?):
SKIN (describe:lumps, bruising, rashes, varicisoties, swellings, itching, discolorations):
MUSCULOSKELETON ( describe:pain, numb, tingle, paralysis, weakness, spasms, stiffness):
Headache & DIZZINESS (describe: pain, balance, vertigo, seizures):
Eyes, Ears, Nose, Throat (describe: itchy, dry, tearing, pain, discharge,burning):
CARDIAC (describe: pain, palpitations, murmurs, edema):
RESPIRATORY (describe: cough, Shortness of Breath, wheezing, sputum, asthma, allergies, hay
fever):
APPETITE/DIGESTION (describe:a good appetite? any problems with digestion like gas,
bloating, belching, heartburn, nausea, vomiting, hunger, pain? Food intake):
ELIMINATION (describe: daily bowel movements? Normal is well formed, brown, mild smell, 13x/day; any problems with constipation, diarrhea, loose stool, undigested food in the stool, sticky,
pain, blood in the stool):
THIRST/DRYNESS (describe: are you thirsty or not thirsty? do you have problems with dry hair,
skin, stool or other):
URINATION (describe: frequency, is there any irritation, strong smell or difficulty? do you
have incontinence or wake at night to urinate?):
MALES:
Add any additional information you think may be relevant:
FEMALES:
Menarche (date/age of beginning of menses) ______ Menopause ______Cycle Length________
Duration of bleeding (in days) ______
Quality (describe: color, pain, clots, flow)___________________
PMS (describe): _____________________________________________________________
Menopause (describe):
___________________________________________________________
Last PAP ______________ Ever Abnormal? _______________
Discharge __________________________________________________________
Birth control/ Disease prevention Methods ________________________________________
Pregnancies_________ Births _________Abortion________ Miscarriage________
Complications _____________________________________________________
Add any additional information you think may be relevant:
Please Check if you have experienced any of the following in the last 3 months:
General
___Poor Appetite __Localized Weakness __Sudden energy drop __Change in appetite
__Fevers __Poor sleeping __Peculiar tastes/smells __Hearing Loss __Fatigue __Excess Thirst
__Bleeding/Bruising Easily __Sweat Easily __Tremors __Poor Balance __Weight Loss
__Night Sweats __Cravings __Chills __Weight Gain
Skin & Hair
__Rashes __Itching __Dandruff __Ulceration __Eczema __Loss of Hair __Hives __Pimples
__Recent Moles
Head, Eyes, Nose, Throat
__Dizziness __Glasses __Poor Vision __Grinding of Teeth __Ringing in Ears __Sinus Problems
__Cataracts __Teeth Problems __Gum Problems __Headaches __Concussions
__Spots in Front of Eyes __Night Blindness __Blurring Vision __Poor Hearing __Nose Bleeds
__Facial Pain __Jaw Click __Migraines __Lip/Tongue Sores __Color Blindness __Earaches
__Eye Strain __Recurrent Sore Throats __Eye Pain __Difficulty swallowing
Cardiovascular
__Blood Clots __Fainting __Cold Hands or Feet __High Blood Pressure __Phletitis __Dizziness
__Swelling of Hands __Low Blood Pressure __Chest Pain __Swelling of Feet __Irregular
Heartbeat __Difficulty Breathing
Respiratory
__Cough __Bronchitis __Asthma __Labored Respiration __Wheezing __Pnuemonia
__Shortness of Breath __Painful Breathing
Gastrointestinal
__Nausea __Constipation __Coughing up Blood __Bad Breath __Belching __Phlegm
__Difficulty breathing __Intestinal Gas __Diarrhea __Rectal Pain __Blood in Stools
__Abdominal Pain __Indigestion __Hemorrhoids __Black Stools __Vomiting
Genito-Urinary
__Pain on urination __Urgency to urinate __Decrease in Urine Flow __Frequent Urination
__Blood in urine __Impotency __Unable to Hold Urine __Frequent Night Urination
__Genital sores __Kidney Stones __Discolored Urine
Musculo-Skeletal
__Neck Pain __Back Pain __Hand/Wrist Pain __Muscle Pains __Scoliosis __Shoulder Pain
__Knee Pain __Foot/Ankle Pain __Hip Pain __Arthritis __Muscle Weakness
Gynecology-Pregnancy
__Irregular Period __Painful Periods __Vaginal Discharge___ # of Pregnancies_______
__Clots __Last PAP ____________ __Vaginal Sores ___# of Births_____________
__Premature Birth __Abortions ___________ __Miscarriages Age of 1st Menses___________
__Light Flow __Duration of Flow _______ __Heavy Flow Date of Last Menses________
Neuro-Psychological
__Seizures __Numb Body Areas __Concussion __Bad Temper __Dizziness
__Lack of Concentration __Depression __Loss of Balance __Stress __Poor Memory
__Anxiety __Mood Swings