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1 Catherine M. Gurski, ND, MSOM, LAc. 1962 NW Kearney, Suite 102 Portland, OR 97209 503-274-4360 Patient Health History Patient’s name: _____________________________________________________________________________ Please Print (Last) (Middle) (First) Address: _____________________________________________________________________________________ Street or POB _____________________________________________________________________________________ City, State, Zip Phone: ___________________________________ Email: _______________________________ ____________________________________ Cell: _________________________________ Home Work with extension Date of Birth: __________________________ Age: ______ Female: ______ Male: ______ Preferred Name: ______________________________ Occupation: ______________________________________ Employer: ___________________________ Emergency Contact: _____________________________ Relationship: ________________________ Phone: ____________________________________________ How many children do you have? _________________________________ Social: _____single _____married Living with: ______spouse _____children How did you hear about me? ______other _____friends _____separated _____roommates ______children part-time _____alone ____From a friend ____Flyer _____divorced _____parents ______other ____Website ____Practitioner/Doctor ____Business card ___Other:____________________ Please check any services that you are interested in now or in the future. ____Massage ____Shiatsu ____Acupuncture ____Naturopathic Medicine ____Counseling ____Sports Medicine ____Meditation ____Herbal Medicine ____CranioSacral ____Qi Gong 2 Catherine M. Gurski, ND, MSOM, LAc. 1962 NW Kearney, Suite 102 Portland, OR 97209 503-274-4360 When did you last go to a doctor’s office, medical office or hospital? What was the reason? What are your most important health concerns? What hospitalizations or surgeries have you had? What diagnostic imaging have you had? _____EKG ______Ultrasound ______MRI _____CT ______Bone Density (DEXA) ______X-rays ______mammogram other _______________________________ Please list all current medications and supplements: Please check any of the following that you currently take: ___Pain Relievers (Aspirin/Tylenol/Advil) ___Hormone Replacement Medication ___Cortisone (cream or pills) ____Hormonal Birth Control 3 Catherine M. Gurski, ND, MSOM, LAc. 1962 NW Kearney, Suite 102 Portland, OR 97209 503-274-4360 ___Thyroid medication ___Sleep aids ___Antacids (Rolaids/Tums) ___Laxatives ___Anti-anxiety ____Antidepressants _____Anticonvulsants/Antiseizure Do you have allergies to foods, drugs, animals, pollens, etc.? Please list: Please check the immunizations that you have had? Place a (?) if you do not know. ____Diptheria ____Measles/Mumps/Rubella ____Polio ____Pertussis ___Tetanus Have you had the following illnesses? Scarlet Fever yes no Diptheria yes no Rheumatic Fever yes no Mumps yes no Measles yes no German Measles yes no Other ____________________________________________________________ Please check any of the following that you or your family members have experienced: Cancer ___self ___father ___mother ____brother ___sister ___children Diabetes ___self ___father ____mother ____brother ____sister ____children Heart Disease ___self ___father ____mother ____brother ___sister ____children High Blood Pressure ___self ___father ___mother ___brother ____sister ___children Stroke ____self ____father ____mother ____brother Epilepsy ____self ____father ____mother ____brother ____sister ____children Mental Illness ____self Asthma ____self ____sister ____children ____father ____mother ____brother ____sister ____children ____father ____mother ____brother ____sister ____children Hay fever/Hives ____self ____father ____mother ___brother ___sister ___children Anemia ____self ____father ____mother ____brother ____sister ____children 4 Catherine M. Gurski, ND, MSOM, LAc. 1962 NW Kearney, Suite 102 Portland, OR 97209 503-274-4360 Kidney Disease ___self Liver Disease ___self ___father Gallbladder Dz ___self Ulcer ___self Arthritis ___self ___self ___father ___father ___brother ___brother ___mother ___mother ___mother ___father ___sister ___sister ___children ___children ___mother ___brother ___sister ___children ___mother ___father Heart Murmur ___self ___mother ___mother ___brother ___father ___father Tuberculosis ___self Goiter ___father ___sister ___brother ___brother ___brother ___mother ____children ___sister ____children ___sister ____children ___sister ____children ___brother ___sister ___children Cataracts ___self ___father ___mother ___brother ___sister ____children Glaucoma ___self ___father ___mother ___brother ___sister ____children GENERAL Weight_____ Weight one year ago______ Energy Level_____ (0—5) 0 = none Height_____ 5 = excess What are you hobbies and interests? Do you exercise and if so how many days per week? What type of exercise do you do? Do you eat three meals a day? Do you sleep well? Do you awake rested? Do you average 6 to 8 hours of sleep? Do you enjoy your work? Do you spend time outside? Do you take vacations? ___ yes ___ yes ___ yes ___ yes ___ yes ___ yes ___ yes How many hours of TV do you watch per day? ___ no ___ no ___ no ___ no ___ no ___ no ___ no _______ 5 Catherine M. Gurski, ND, MSOM, LAc. 1962 NW Kearney, Suite 102 Portland, OR 97209 503-274-4360 Do you use recreational drugs? Do you use tobacco? Do you drink alcoholic beverages? Have you been treated for alcoholism? Have you been treated for drug dependence? REVIEW OF SYSTEMS Circle the response that applies Y = present condition SKIN Rashes Y Eczema/Hives Y Acne/Boils Y Itching Y Color change Y Lumps Y Night Sweats Y HEAD Headache Y Head Injury Y Migraines Y EYES Impaired vision Y Glasses/contacts Y Eye Pain Y Tearing/dryness Y Double vision Y Glaucoma Y Cataracts Y EARS Impaired hearing Y Ringing Y Earache Y Dizziness Y NOSE/SINUSES Frequent colds Y Nose bleeds Y Stuffiness Y Hay Fever Y Sinus problems Y MOUTH/THROAT Many sore throats Y Sore tongue Y Canker sores Y Gum Problems Y Hoarseness Y NECK Lumps Y Swollen glands Y Goiter Y Pain/Stiffness Y RESPIRATORY Cough Y Sputum Y Spitting blood Y Wheezing Y ___ yes ___ yes ___ yes ___ yes ___ yes P = past condition ___ no ___ no ___ no ___ no ___ no N = never a condition P P P P P P P N N N N N N N URINARY Pain on urination Increased frequency Frequency at night Inability to hold urine Frequent infections Kidney stones P P P N N N FEMALE REPRODUCTIVE Age menses began Average number days Length of cycle Age of last menses Bleeding between periods Are cycles regular Painful menses Excessive flow Painful intercourse Type of Birth Control Number of Pregnancies Number of live births Number of miscarriages Number of abortions Difficulty conceiving Menopausal symptoms Breasts lumps Breast pain/tenderness Nipple discharge Perform self breast exam Date of last menses Sexually active Sexual difficulties Venereal disease Sexual Preference ____Hetero _____Bi MALEREPRODUCTIVE Hernias Testicular masses Sexually active Sexual difficulties Prostate disease Venereal disease Discharge or sores Sexual preference ____Hetero ____Bi P N P N P N P N P N P N P N P N P N P N P N P P P P P N N N N N P P P P P N N N N N P P P P N N N N P P P P N N N N Y Y Y Y Y Y P P P P P P N N N N N N __________ __________ __________ days __________ Y P N Y P N Y P N Y P N Y P N ____________ ____________ ____________ ____________ ____________ Yes No Y P N Y P N Y P N Y P N Y P N Y P N Y P N Y P N Y P N Y P N ____Homosexual Y Y Y Y Y Y Y P P P P P P P N N N N N N N _____Homosexual 6 Catherine M. Gurski, ND, MSOM, LAc. 1962 NW Kearney, Suite 102 Portland, OR 97209 503-274-4360 RESPIRATORY Asthma Y P N Bronchitis Y P N Pneumonia Y P N Pleurisy Y P N Emphysema Y P N Difficult breathing Y P N Shortness of breath Y P N at night Y P N lying down Y P N Tuberculosis Y P N CARDIOVASCULAR Heart disease Y P N Angina Y P N High BP Y P N Murmurs Y P N Rheumatic fever Y P N Chest Pain Y P N Palpitations Y P N Swelling in ankles Y P N GASTROINTESTINAL Trouble swallowing Y P N Heartburn Y P N Change in thirst Y P N Change in appetite Y P N Nausea Y P N Vomiting blood Y P N Bowel movements—how often? _______ Is this a change? Yes No Blood in stool Y P N Belching/gas Y P N Jaundice(yellow skin) Y P N Liver disease Y P N Hemorrhoids Y P N NEUROLOGIC Fainting Y P N Seizures Y P N Paralysis Y P N Muscle weakness Y P N Numbness/tingling Y P N Loss of memory Y P N MUSCUL0SKELETAL Joint pain or stiffness Arthritis Broken Bones Muscle spasms/cramps Weakness PERIPHERAL VASCULAR Deep leg pain Cold hands/feet Varicose veins Thrombophlebitis EMOTIONAL Depression Mood swings Anxiety/nervousness Tension Y Y Y Y Y P P P P P N N N N N Y Y Y Y P P P P N N N N Y Y Y Y P P P P N N N N ENDOCRINE Hypothyroid Heat/Cold Intolerance Excessive thirst Excessive hunger Y Y Y P P P N N N BLOOD Anemia Easy bleeding/bruising Fatigue Y Y Y P P P N N N I hereby certify that I have supplied correct and accurate information to the best of my knowledge. Name_________________________________________________ SIGNATURE Name_________________________________________________ PRINTED Date_________________________
