WELLNESS & REJUVENATION CENTER
PATIENT’S RECORD
NAME: ______________________________________________________
Date: ______________
ADDRESS: ___________________________________________________________________________
AGE: _____ SEX: ____ STATUS: _____ CITIZENSHIP: __________ Tel#: _______________
SOURCE OF REFERRAL: _____________________________________________________________________
SOURCE OF HISTORY: _______________________________________________________________________
CHIEF COMPLAINT: (What, When it started, How long, Solution Taken)
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MEDICAL HISTORY: (What Illness, When, Who/Where Treated, Treatment Done)
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FAMILY HISTORY: (Relationship, Cause of Death/What Illness, When)
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HISTORY OF ALLERGY: (What, When, Who/Where Treated, Treatment Done)
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PSYCHOSOCIAL & DIETARY HISTORY:
Religion: _____________________________________
Occupation: __________________________
Smokes? _____
What: ____________________
How many: __________
Drinks Milk? _____ What: ____________________ How many times: __________
Exercises? _____
What: ______________________________________ How long: ___________
What food are you fond of eating? _________________________________________________________
Sleep Patterns: ________________________________________________________________________
Are you on any other health therapy now? _____ What: ______________________________________
Describe: _____________________________________________________________________________
Home Situation & Daily Life: (Who lives with you? Who helps you when you’re sick or need assistance?
Describe them and also your friends. What is your daily routine like from time of arising to bedtime?)
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I certify that I have read and understand all the questions set forth and the information provided are true
and correct to the best of my knowledge.
After knowing & understanding the treatment approach use in this system of medical management, I also
on my own volition subject myself for treatment.
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Patient’s Signature
PERTINENT PHYSICAL FINDINGS:
General Survey:
Height: _____ Weight: _____
Sensorium: (Alert, Drowsy, Lethargic/Stuporous, Semicoma or Coma/Comatose)
Attention Span: (Confused, Grossly disoriented, Demented)
Orientation: to Time? _______________ Place? _______________ Person? _______________
Communication Ability: Can express or communicate thoughts or needs? ___ (Verbally, in Writing or by Gestures). If able
to communicate verbally, is it (Clear or Dysarthria, Coherent or Incoherent), Can understand and respond appropriately
to question or task? _________ What form of communication is he responsive to? (verbal, gestural or written). If able
to comprehend, can follow instructions? ____________
Physique or built of patient: (Endomorphic, Ectomorphic, Mesomorphic, Sthenic, Hypersthenic, Hyposthenic or Asthenic).
Nutritional Status: (Well-nourished, Overnourished/Obese, Undernouriished) If undernourished, what degree? ________
Development: (Well-developed, Fairly developed, Underdeveloped)
Ambulation Status: (Bedridden, Wheelchair-borne, ambulant with or without assistance)
Severity of Illness: (Presence or absence of an apparent distress and its relative intensity) If having difficulty in breathing, is
respiratory distress (mild, moderate or severe). In pain? ___ intensity? Depressed? _____ intensity? _____
Vital Signs:
Usual BP: _______
BP: _______
HR: ______
PR: ___ Rhythm: ________ RR: __
 Skin: (Rashes, lumps, sores, itching, dryness, color change, changes in hair & nails) _______________________________
 Head: (Headache, head injury) __________________________________________________________________________
 Eyes: (Vision, glasses or contact lenses, pain, redness, tearing, blurring, double vision, spots or specks, glaucoma, cataracts,
last eye examination) _____________________________________________________________________________
 Ears: (Decreased hearing, tinnitus, vertigo, earaches, infection, discharges, hearing aids) ____________________________
 Nose & Sinuses: (Frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble) ______________
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 Mouth & Throat: (Dry mouth, sore tongue, frequent sore throats, hoarseness, condition of teeth & gums, bleeding gums,
dentures?, if any, how they fit & last dental examination) ________________________________________________
 Neck: (Lumps, “swollen glands”, goiter, pain or stiffness) ____________________________________________________
 Breast: (Lumps, pain or discomfort, nipple discharge, self-examination?) ________________________________________
 Respiratory: (Cough, sputum (color & quantity), hemoptysis, wheezing asthma, bronchitis, emphysema, pneumonia,
tuberculosis, pleurisy; last x-ray film) ________________________________________________________________
 Cardiac: (Heart trouble, high blood pressure, rheumatic fever, heart murmur, chest pain or discomfort, palpitations,
dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past ECG or other heart test) _______________________
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 Gastrointestinal: (Trouble swallowing, heartburn, appetite, nausea, vomiting, regurgitation, vomiting blood, indigestion;
Frequency of vowel movements, color & size of stools, change in bowel habits, rectal bleeding or black tarry stools,
hemorrhoids, constipation, diarrhea; Abdominal pain, food intolerance, excessive belching or passing of gas, jaundice,
liver or gallbladder trouble, hepatitis) ________________________________________________________________
 Urinary: (frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or
force of urinary stream, hesitancy, dribbling, incontinence, urinary infections, stones) _________________________
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 Genitals: (Discharge, itching, sores, lumps, STD and treatments done, Sexual preference, interest, function, satisfaction and
problems; MALE: Hernia? FEMALE: Age at menarche, regularity, frequency, and duration of periods, amount of
bleeding, bleeding between periods or after intercourse, last menstrual period; age at menopause, menopausal
symptoms, postmenopausal bleeding) ________________________________________________________________
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 Peripheral Vascular: (Intermittent claudication, leg cramps, varicose veins, past clots in the veins) ____________________
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 Musculoskeletal: (Muscle or joint pains, stiffness, arthritis, gout, backache. If present describe location & symptoms, i.e.;
swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion or activity) ________________________
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 Neurologic: (Fainting, blackouts, seizures, weakness, paralysis, numbness, tingling or “pins & needles”, tremors, other
involuntary movements)___________________________________________________________________________
 Hematologic: (Anemia, easy bruising or bleeding, past transfusions and any reactions)______________________________
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 Endocrine: (Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria)
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 Psychiatric: (Nervousness, tension, mood including depression, memory)
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DIAGNOSIS: ________________________________________________________________________________
INITIAL TREATMENT: _____________________________________________________________________
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WELLNESS & REJUVENATION CENTER
FOLLOW-UP RECORD
NAME: ______________________________________________________
Page: ______________
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PATIENT FEEDBACK/COMPLAINT:
Date: __________ BP: ________ Weight: ________ Height: ________
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ASSESSMENT/FOLLOW-UP TREATMENT:
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PATIENT FEEDBACK/COMPLAINT:
Date: __________ BP: ________ Weight: ________ Height: ________
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ASSESSMENT/FOLLOW-UP TREATMENT:
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PATIENT FEEDBACK/COMPLAINT:
Date: __________ BP: ________ Weight: ________ Height: ________
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ASSESSMENT/FOLLOW-UP TREATMENT:
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PATIENT FEEDBACK/COMPLAINT:
Date: __________ BP: ________ Weight: ________ Height: ________
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ASSESSMENT/FOLLOW-UP TREATMENT:
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PATIENT FEEDBACK/COMPLAINT:
Date: __________ BP: ________ Weight: ________ Height: ________
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ASSESSMENT/FOLLOW-UP TREATMENT:
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PATIENT FEEDBACK/COMPLAINT:
Date: __________ BP: ________ Weight: ________ Height: ________
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ASSESSMENT/FOLLOW-UP TREATMENT:
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