New Patient Health History

Ted Suzelis, ND and Rachael O'Connell, ND

Instructions

Please fill out this form to the best of your ability and ignore any questions that don't pertain to you, you don't know the answer, or you feel uncomfortable answering. Call or text our office with any questions or concerns.

Boardman: 330-729-1350
Newton Falls: 330-872-1577

Patient Information

First name

Last name

Address

City

State

Zip

Home phone number

Cell phone number

Email address

Preferred Contact Method(s)

Home Phone

Cell Phone

Text

Email

Date of birth

Age

Occupation

Employer

Status

Full-time Part-Time

Name of Spouse or Partner

Contact number

Name of Parent

Contact Number

Emergency Contact

Contact number

Referral Name

Last physician or health care provider seen

When was your last blood test?

What kind?

Your Current Health Concerns

What is your main reason for coming to our office?

If you have a specific health condition, please describe it in detail. When was the very first time that you noticed your condition and describe carefully any factor that you suspect may have played a role in its onset and its continuation.

How long has your MAIN health concern been troubling you?

and for how long?

List in order of importance other health concern that are troubling you:

Health Concern 1

Length of Time

Health Concern 2

Length of Time

What is your interest level in the following therapies?

Your Health History

When during the day is your energy the best?

When during the day is your energy the worst?

What is your current approximate weight?

What was your weight one year ago?

Highest weight as an adult? (excluding pregnancy)

Lowest weight as an adult?

What is your height?

Feet

Inches

Please list the 5 most significant, stressful events in your life, from the most recent to the most distant.

Event 1

Date(s)

Event 2

Date(s)

Event 3

Date(s)

Event 4

Date(s)

Event 5

Date(s)

Are any of these situations continuing to impact your life?

Yes No

Are you currently working with a professional counselor, psychologist, pastor or other therapist?

Yes No

Have you in the past

Yes No

If so, when? (give dates)

Medical History

Have you been treated by a doctor of conventional medicine (MD or DO) in the last 12 months?

Yes No

If yes, please describe the reason for your visit and who the doctor is:

When was your last physical exam?

Any other Diseases

Previous Hospitalizations/Surgeries

When?

Hospital, City, State

Do you have any known allergies to any drugs, foods, animals, herbs, or other substance?

Yes No

If Yes, allergies to what?

Which of the following do you currently use? (list how often, how much and how long for each)

Alcohol

Tobacco

Hormones

Coffee

Steroids

Laxatives

Sedatives

Antacids

Other Prescription Medications (please give full name, dosage, and how long you have been taking the medications)

Vitamins or Supplements (please give full name, dosage, and how long you have been taking them)

Family History

Please list ages, health problems, and if deceased, age at death and cause of death.

Your Mother's Age

Health Problems

Age Died and Cause of Death

Your Father's Age

Health Problems

Age Died and Cause of Death

Your Brother's Age

Health Problems

Age Died and Cause of death

Your Sister's Age

Health Problems

Age Died and Cause of Death

Mother's Mom

Health Problems

Age Died and Cause of Death

Mother's Dad

Health Problems

Age Died and Cause of Death

Father's Mom

Health Problems

Age Died and Cause of Death

Father's Dad

Health Problems

Age Died and Cause of Death

Your Spouse

Health Problems

Age Died and Cause of Death

What is your nationality?

Do you have any children?

Yes No

If yes, how many?

What is your weakest organ system and why?

Personal Habits

What do you enjoy most in your life?

What are your main interests or hobbies?

What do you worry most about in life?

Do you exercise?

Yes No

If yes, what kind, how much & how often?

Do you have a religious or spiritual practice?

Yes No

If yes, what?

How many hours do you sleep at night?

Do you have problems

Falling asleep

Staying asleep

Do you wake up feeling refreshed?

Yes No

Do you awaken at night?

Yes No

If yes, what time(s) do you usually wake up?

Do you ever sweat at night while sleeping?

Yes No

How frequently and how much do you sweat?

Do you nap or rest horizontally during the day?

Yes No

If yes, for how long?

What do you normally feel like, temperature wise, compared to others?

Warmer Cooler Average

What are the temperatures of your hands and feet generally?

Warmer Cooler Average

Do you enjoy your work?

Yes No

Do you take vacations?

Yes No

Are you currently in a happy, satisfying relationship with someone?

Very Mostly Somewhat Not

How often do you get colds, flus, sore throats, or yeast infections during the year?

When you rise quickly from a sitting or lying position, do you ever get dizzy?

Yes No

If yes, how often?

daily few times a week weekly twice a month monthly rarely

What are your health goals for 1 year from now?

What are your health goals for 5 years from now?

Female Reproduction

Age of first menses

If periods have stopped, at what age did they stop?

Are your cycles regular?

Yes No

Period begins every X days?

How many days does period last?

Are your periods

heavy

medium

light

Do you experience cramps?

Severe Mild None

What color is the blood?

light red

dark red

medium

clots

Do you have any premenstrual symptoms (PMS)?

water retension

breast tenderness

irritability

depression

mood swings

food cravings

acne

digestive symptoms

Other PMS symptoms:

Number of pregnancies

Number of live births

Number of miscarriages

Number of abortions

Any trouble getting pregnant?

Yes No

Do you get annual PAP smears?

Yes No

Any abnormal PAP smears?

Yes No

Breast lumps?

Yes No

Any questions or problems concerning sex?

Any pain or discomfort with sexual intercourse?

Yes No

Do you use birth control?

Yes No

If so, what type?

Have you ever been physically or sexually abused?

Yes No

How old and how often?

Male Reproduction

How many times do you urinate at night?

Is this an increase in the last few years?

Yes No

Any problems with erectile dysfunction?

Yes No

Any sores on your penis?

Yes No

Do you have any abnormal discharge from the penis?

Yes No

Any known venereal diseases?

Yes No

Any prostate problems?

Yes No

Ever have your prostate examined?

Yes No

When?

Do you use birth control?

Yes No

If yes, what type?

Have you ever been physically or sexually abused?

Yes No

How old and how often?

Digestion

Do you have any problems with gas, bloating or fullness after eating?

Yes No

Do you have gas your abdomen?

upper part/belching

lower part/flatulence

How long have you had gas problems?

How often do you have a bowel movement?

Do you ever have any of the following in your stool?

blood

mucous

undigested food

black tar

Any anal/rectal itching?

Yes No

Do you ever have alternating constipation and diarrhea?

Yes No

Have you ever fasted?

Yes No

Water or juice fast?

water juice

How many days did you fast?

Have you traveled outside the US in the last 5 years?

Yes No

Have you gone camping in the last 5 years?

Yes No

Kidneys and Bladder

Have you had recurrent urinary tract infections?

Yes No

How were they treated?

How many urinary tract infections have you had in the last 3 years?

Do you ever have a burning sensation during or after urination?

Yes No In Past

Does your urine have a strong odor?

Yes No

Do you have difficulty starting or stopping when urinating?

Yes No

Do you have difficulty perspiring?

Yes No

Do you perspire profusely?

Yes No

Does your perspiration have a strong odor?

Yes No

What other beverages do you drink and how much?

Occupational/Household

How long have you lived at your current location?

Years

Months

Is it?

damp

moldy

dry

dusty

Where have you lived previously?

Was it?

damp

moldy

dry

dusty

Do you have specialized air filtration at home?

Yes No

Do you live in the city?

Yes No

Do you work in an office building?

Yes No

Do the windows open?

Yes No

Do you have specialized air filtration at your work place?

Yes No

Do you work in the presence of toxic fumes or chemicals?

Yes No

Do any of your hobbies involve toxic materials?

Yes No

Are you exposed to second hand smoke on a regular basis?

Yes No

What do you use for your drinking water?

Bottled

Filtered

Tap

Do you have anything else you would like to share with the doctor?

Please check box when you are finished filling out questionnaire and then click the Submit Questionnaire button below.

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