Your Natural Path Wellness Center
Dr. Anorah C. Schostag, N.D.
2433 Hedgesville Road, Martinsburg, WV 25401
Phone: (614) 302-2028
Adolescent Intake
10-17 Years of Age
Name (First, Middle, Last) _________________________________________
Date_________________
Age __________ Date of Birth _____________________________ Sex:
M
F
Mother or Guardian _________________________ Father or Guardian _________________________
Address ___________________________________________ City ____________________________
State _________ Zip ___________ Telephone (Home) ________________________
Education ____________________ Hours per week ________ Hours of homework per week _______
Are you:
Next of kin or other to reach in an emergency _______________________________________
Relationship _________________ Address ________________________________________
Telephone (Home) ______________________ Telephone (Work) ______________________
How did you hear about the clinic? ______________________________________________________
Health History Questionnaire
Holistic health care and preventative medicine are only possible when the physician has complete
understanding of the patient physically, mentally, and emotionally. Please complete this questionnaire
as thoroughly as possible. Print all information and mark anything you don’t understand with a
question mark.
When and where did you last receive medical or health care?
___________________________________________________________________________
What was the reason? _________________________________________________________
What are your most important health problems? List as many as you can in order of importance.
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________
6. ________________________________________________________________________
1
Family History
Check those applicable Father
Mother
Brothers
Sisters
Spouse
Children
Age (if living)
_______
_______
_______
_______
_______
_______
Health G= good P= poor _______
_______
_______
_______
_______
_______
Cancer
_______
_______
_______
_______
_______
_______
Diabetes
_______
_______
_______
_______
_______
_______
Heart Disease
_______
_______
_______
_______
_______
_______
High Blood Pressure
_______
_______
_______
_______
_______
_______
Stroke
_______
_______
_______
_______
_______
_______
Epilepsy
_______
_______
_______
_______
_______
_______
Mental Illness
_______
_______
_______
_______
_______
_______
Asthma,Hayfever,Hives _______
_______
_______
_______
_______
_______
Anemia
_______
_______
_______
_______
_______
_______
Kidney Disease
_______
_______
_______
_______
_______
_______
Glaucoma
_______
_______
_______
_______
_______
_______
Tuberculosis
_______
_______
_______
_______
_______
_______
Age (at death)
_______
_______
_______
_______
_______
_______
Cause of death
_______
_______
_______
_______
_______
_______
Previous pregnancies by natural mother, miscarriages or complications: _________________________
___________________________________________________________________________________
___________________________________________________________________________________
Mother's age at child's birth _______
Mother's health during pregnancy:
___ bleeding
___ hypertension ___ illness
___ cigarettes, alcohol, drugs
___ nausea
___ diabetes
___ thyroid problems
___ physical or emotional trauma
Birth History
Term: full ___
premature ___
late ___
weight at birth ______________
length of labor ________________ complications __________________________________________
As a baby, did your child have any of the following problems?
___ jaundice
___ diarrhea
___ birth defects
___ rashes
___ colic
___ fever
___ cerebral palsy
___ allergies
___ blue baby
___ seizures
___ birth injuries
___ other ___________________
Feeding: breast fed ___ how long? ___ formula ___ milk ___ soy ___
Age the child began: solid foods _____ sitting _____ crawling _____ walking _____
First words ___________________________________
Child's sleep patterns during the first year _________________________________________________
___________________________________________________________________________________
2
Immunizations
___ measles
___ polio
___ MMR
___ small pox
___ diphtheria
___ mumps
___ DPT
___ tetanus
___ influenza
___ others ________________
Any adverse reactions to immunizations? (Please specify) ____________________________________
___________________________________________________________________________________
Childhood Illnesses
___
___
___
___
chicken pox
measles
mumps
croup
___
___
___
___
scarlet fever ___ bronchitis
___ tonsillitis, no. of times ____
pneumonia
___ rubella
___ ear infections, no. of times ____
frequent cold ___ eczema
___ asthma
other _________________________________________________________
Medications
now past
aspirin
___ ___
tylenol
___ ___
inhalers
___ ___
__________ ___ ___
others
Do you take or use?
Laxatives
Y N
Cortisone
Y N
Tranquilizers
Y N
now
antibiotics ___
anti-histamine___
asthma meds ___
__________ ___
past
___
___
___
___
Pain relievers
Appetite suppressants
Thyroid medication
Y
Y
Y
now
decongestant ___
ibuprofen
___
topical steroids ___
___________ ___
N
N
N
Antacids
Sleeping pills
Y
Y
past
___
___
___
___
N
N
Allergies to medicines_________________________________________________________________
X-Rays and Special Studies
when
where
results
electroencephalogram ________________________________________________________________
psychological evaluation ______________________________________________________________
hearing ____________________________________________________________________________
speech/language _____________________________________________________________________
Injuries/ Surgeries/ Hospitalizations
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Review of Symptoms
Please circle: Y = a condition your child has now. N = never had. P = has had in the past.
General
Weight _________
Weight 1 year ago______
3
Max weight _____
When ______
Height _________
Fatigue Y P N
Skin
Rashes
Acne
Night sweats
Y P N
Y P N
Y P N
Eczema, Hives
Color change
Y P N
Y P N
Itching
Lumps
Y P N
Y P N
Head
Headache
Y P N Head injury
Y P N
Impaired vision
Eye Pain
Double vision
Cataracts
Y
Y
Y
Y
Y P N
Y P N
Y P N
Eyes
P
P
P
P
N Glasses or contacts
N Tearing or dryness
N Glaucoma
N
Ears
Impaired hearing
Earache
Nose and Sinuses
Frequent colds
Stuffiness
Sinus problems
Mouth and Throat
Frequent sore throat
Gum problems
Dental cavities
Neck
Lumps
Goiter
Respiratory
Cough
Sputum
Asthma
Pneumonia
Pleurisy
Pain on breathing
Shortness of breath
Short/breath at night
Cardiovascular
Heart disease
High blood pressure
Palpitations, fluttering
Swelling in ankles
Gastrointestinal
Y P N Ringing
Y P N Dizziness
Y P N
Y P N
Y P N Nose bleeds
Y P N Hay fever
Y P N
Y P N
Y P N
Y P N Sore tongue
Y P N Hoarseness
Y P N
Y P N
Y P N
Y P N Swollen glands
Y P N Pain or stiffness
Y P N
Y P N
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
N
N
N
N
N
N
N
N
Spitting up blood
Wheezing
Bronchitis
Emphysema
Difficulty breathing
Tuberculosis
Short/breath lying down
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
N
N
N
N
N
N
N
Y
Y
Y
Y
P
P
P
P
N
N
N
N
Angina
Murmurs
Rheumatic fever
Chest pain
Y
Y
Y
Y
P
P
P
P
N
N
N
N
4
Trouble swallowing
Change in thirst
Nausea
Vomiting blood
Bowel movements
Blood in stool
Jaundice (yellow skin)
Gall bladder disease
Hemorrhoids
Urinary
Pain on urination
Frequency at night
Frequent infections
Female Reproductive
Average number of days
Regular cycles
Pain during intercourse
Excessive flow
Breasts
Do you do self exam?
Pain or tenderness
Male Reproductive
Hernias
Testicular pain
Muscoskeletal
Joint or pain stiffness
Broken bones
Muscle spasms / cramps
Peripheral Vascular
Deep leg pain
Varicose veins
Neurologic
Fainting
Paralysis
Loss of memory
Emotional
Depression
Mood swings
Endocrine
Hypothyroid
Excessive thirst
Y P N Heartburn
Y P N
Y P N Change in appetite
Y P N
Y P N Vomiting
Y P N
Y P N
How often? ______________ Is this a change? Y N
Y P N Belching, passing gas
Y P N
Y P N Liver disease
Y P N
Y P N Ulcer
Y P N
Y P N
Y P N Increased frequency
Y P N Inability to hold urine
Y P N Kidney stones
Y P N
Y P N
Y P N
_______ Length of cycle
Y P N Bleeding between periods
Y P N Painful menses
Y P N
_______
Y P N
Y P N
Y P N Lumps
Y P N Nipple discharge
Y P N
Y P N
Y P N Discharge or sores
Y P N
Y P N
Y P N Arthritis
Y P N Weakness
Y P N
Y P N
Y P N
Y P N Cold hands or feet
Y P N Thrombophlebitis
Y P N
Y P N
Y P N Seizure
Y P N Muscle weakness
Y P N Numbness
Y P N
Y P N
Y P N
Y P N Anxiety or nervousness
Y P N Tension
Y P N
Y P N
Y P N Heat or cold intolerance
Y P N Excessive hunger
Y P N
Y P N
5
Blood
Anemia
Y P N Easy bleeding
Y P N
Any other condition not mentioned? ____________________________________________________
__________________________________________________________________________________
Habits
What are you main interests and hobbies? ______________________________________________
__________________________________________________________________________
Do you exercise? Y N What forms? ______________________________________
How often? __________________________________________________________
Do you eat three meals daily
Average 6-8 hours sleep
Enjoy school
Watch television
Read
Take vacations
Use recreational drugs
Use alcoholic beverages
Use tobacco
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
Awaken rested
Sleep well
Spend time outside
How many hours/day (TV)
How many hours/day (Read)
Y N
Y N
Y N
____
____
Been treated for drug dependence
Been treated for alcoholism
Y N
Y N
Diet
Please describe your child's typical daily diet: ______________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Food intolerances (if known)___________________________________________________________
___________________________________________________________________________________
_____________________________________
_____________
Patient's or Authorized Person's Signature
Date
6