Adult medical intake - part 3

Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES 48. Any other family history we should know about? ___________________________________________________________________ 49. What is the attitude of those close to you about your illness? !FOR WOMEN ONLY (questions 50-58):
!50.Have you ever been pregnant? (If no, skip to question 53.) ! Number of miscarriages _____ Number of abortions _____ ! Number of term births _____ Birth weight of largest baby _____ Smallest baby _____ ! Did you develop toxemia (high blood pressure)? ! Have you had other problems with pregnancy? ! If so, please comment: ___________________________________________________________________ _____________________________________________________________________________________ !51.Age at first period _____ Date of last Pap Smear __________ Date of last !52.Have you ever used birth control pills? Yes____ No____ If yes, when _________ If yes, what type of contraception do you use? _______________________________________________ !56.Are you in menopause? No _____ Yes _____ If yes, age at last period______ Progesterone?___ Provera? ___ Other (specify) _______________ !57.How long have you been on hormone replacement therapy (if applicable)? _________________ In the second half of your cycle, do you have symptoms of breast tenderness, water Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES !!!!!!FITNESS AND NUTRITIONAL ASSESSMENTS;
!!A. Please complete separate 3-5 day food diary !!B.Are you interested in the use of exercise as medicine? That is, to use prescribed exercise for disease prevention and disease modification. Yes Not now !C. Do you have other goals for exercise? Please explain: !!!!!!!!!!!!D. What barriers have there been in the past to prevent you from sticking with an exercise program? !!!!!!!!!!E. If weight loss and control have been difficult for you, please list your areas of frustration. Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES 59. Please check if these symptoms occur presently or have occurred in the past 6 months.
GENERAL:
Mild Mod Sever
MUSCULOSKELETA Mild Mod Sever
HEAD, EYES &
MOOD/NERVES:
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES DIGESTION:
MOOD/NERVES,
Mild Mod Sever
Cont’d:
DIGESTION, Cont’d: Mild Mod Sever
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES SKIN PROBLEMS:
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES SKIN PROBLEMS,
Mild Mod Sever
Cont’d:
SKIN, DRYNESS OF: Mild Mod Sever
SKIN, ITCHING:
LYMPH NODES:
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES RESPIRATORY:
Mild Mod Sever
CARDIOVASCULAR:
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES URINARY:
Mild Mod Sever
REPRODUCTIVE:
REPRODUCTIVE:
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES !!!!!!!!KEY QUESTIONS
!!!!When was the last time that you felt well?
!!!!!!!!!What life changing events occured during the year
prior to this time?
!!!!!!!!!!!!!!What life changing events occured during the six
months prior to feeling well?
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES REPRODUCTIVE,
Cont’d:
Copyright The Institute for Functional Medicine Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES !!!!SPIRITUAL/RELATIONAL
!Please briefly answere the following questions. !!Are you involved with a particular Church, Synagogue, Fellowship, Small group, Home Church, Interdenominational Fellowship, Local or overseas Missions or other religeous organization? !!!!!!!!!!Name of Pastor or Spiritual Leader/Mentor !!!!!!Is it OK to contact this person to discuss spiritual matters (non-medical issues) ? !!How have you been spiritually challenged in either a positive or negative way over the past five years? !!!!!!!!!Any concerns about spiritual/church abuse in the past? !!!!!!How do you spiritually enrich yourself, and, how much time do you do this on a weekly/daily basis? !!!!!!Copyright The Institute for Functional Medicine

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