FAMILY HEALTH INFORMATION

(List family members "spouse, father, mother, brother/sisters, and/or children")

PERSONAL HISTORY

IMMUNIZATIONS

List all immunizations you have received, and the date

ALLERGIES

MEDICINES

(Prescription or over the counter)

Have You Ever Taken (Check All That Apply)

DEVICES

Do You Have Any Internal Medical Devices, (i.e. pacemaker or a defibrillator)?

OPERATIONS

Have you had any surgical procedure? If yes, what kind and when?

Please type everything from the following list that you normally use in your diet.

Flesh foods (chicken, pork, beef, seafood), Dairy Products, Sugar, Refined foods (white flour, white rice, white bread, white sugar), Caffeine (Chocolate, soda), Carbonated Beverages, Spices (mustard, vinegar, cinnamon, etc)

DESCRIBE YOUR PERSONALITY TRAITS

Please check everything on the following list that applies to you:

DIAGNOSED DIFFICULTIES BY DOCTORS

What difficulties have you been diagnosed with by your doctor?
Please review the listing found below and indicate appropriately.

LIST OF CONDITIONS

(Migraine Headaches, Epilepsy or Convulsions, Stroke, Glaucoma, Cataracts, Blindness (either eye), Deafness, Asthma, Hay Fever, Chronic Bronchitis, Emphysema, Tuberculosis, Abnormal Chest X-Ray, Heart Murmur as an adult, Abnormal Electrocardiogram, Enlarged heart, Heart Attack, Rheumatic Fever, Angina, High Blood Pressure, Gall Stones, Hepatitis, Cirrhosis of Liver, Stomach or Duodenal Ulcer, Abnormal Stomach X-ray, Colon or Bowel Trouble, Rectal Trouble, Hemorrhoids or Piles, Dysentery or Serious Diarrhea, Kidney or Bladder Infection, Kidney Stones, Other Kidney disease, Poor Blood Clotting, Diabetes, Gout, Overactive Thyroid, Under active Thyroid, Goiter, Parkinson's, MS, Varicose Veins, Arthritis, Polio, Phlebitis, Venereal Disease, Anemia, Insulin, Recurrent boils, Other skin disease, Serious depression, Serious Emotional Problem, Nervous Breakdown.)

WOMEN

(Menstrual difficulties, Ovarian Cyst, Other GYN Problems, Cystitis, Mastitis, Breast Cancer)

FAMILY HISTORY

Please indicate what diseases your blood relatives have suffered from?
Include who that relative was (i.e. brother, sister, mother).

(Cancer, including leukemia, Tuberculosis, Diabetes, Heart Trouble, Heart Attack, High Blood Pressure, Stroke, Epilepsy, Convulsions or fits, Bleeding tendency, Asthma, Allergies, Liver Disease, Migraine Headaches, Alcoholism, Emphysema/lung disease, Stomach or duodenal ulcer, Kidney Disease, Glaucoma, Sickle Cell Anaemia)

SYSTEM REVIEW

Please review the listing found here (hyperlink this to the list of ailments) and indicate what
complaints you may be suffering from?

HEAD: (Blurred vision not corrected by glasses, double vision, light flashes, halos around lights, pain in your eyes, ear pain, drainage from ear, hearing difficulty or deafness, buzzing or ringing in ears, sinus trouble , difficulty swallowing , mouth or tongue problem , persistent hoarseness and Other, explain.)

SKIN: Changing mole, Rash, Yellow skin, Other skin problem , explain.

NECK: Swelling, lumps, stiffness, other Explain

CHEST, HEART, LUNGS: Shortness of breath, Poor exercise tolerance, Fluttering of heart, Unusual heartbeat, Chest pain or pressure attacks, Frequent cough, Coughing up blood, Wheezing swollen ankles, Other, Explain.

GASTROINTESTINAL: Poor appetite, Indigestion or heartburn, Nausea or vomiting, Vomiting blood, Abdominal pain of swelling, Blacktar-like bowel, movements, Abdominal cramps, Other, Explain.

KIDNEY: Blood in urine, Difficulty passing urine, Pain or burning while urinating, Difficulty controlling urine, Getting up at night to urinate, Other, Explain.

GENITALIA WOMEN: Breast lump, Discharge from nipple other breast problem, Vaginal bleeding or spotting (not with periods), hot flashes, pain with intercourse, possibly pregnant, change in periods, pain not associated with periods, other Explain.

GENITALIA MEN: Breast lump, Discharge from penis, Sore on penis, Lump in testicles, Difficulty having erections, Other Explain:

NEUROMUSCULAR: Weakness in arm or leg, Difficulty with balance, Dizzy spells, Fainting spells, Speech difficulty, Other, Explain.
BONE/JOINTS: Painful joints, Swollen joints, Loss of muscle strength, Lump or swelling in muscle, Lump on bone, Back pain, Other, Explain.

ENDOCRINE: Thirsty all the time, cold most of the time, too warm most of the time, unusually tired or sluggish

PSYCHOLOGICAL

Do you find your life:: generally unsatisfactory, too demanding boring, satisfactory?

Do you worry about: money, job, marriage, home life, children?

Do you: Cry easily, Feel inferior to others, Feel shy, Feel things often go wrong, Often feel depressed, Have irrational fears, Feel anxious or upset.

Have you: Seriously considered suicide, attempted suicide

CHIEF COMPLAINTS

What are your chief medical complaints?

Review the list below and indicate what symptoms you are experiencing. Use 1,2,3 or 4 to indicate the
severity of the problem - 4 being the most severe. Please note whether the problem is present,
past or both."

Abnormal thirst, highly emotional, acid Foods, hoarseness, frequent, Acne, hunger between meals, Adenoids, impaired hearing, afternoon headaches, increased amount of urine, afternoon "yawner", can't decide easily, ageing rapidly, can't gain weight, air (swallow air), can't start in AM before coffee, allergies-asthma tendency, can't work under pressure, aluminum cooking utensils, cataracts, ankles swell in evening, chemical or spray poisoning, ankles swell in morning, chemicals in environment, appetite excessive, chronic fatigue, appetite reduced, cigarette cough, Armed Forces Syndrome, circulation poor, arthritic tendencies, sensitive to cold, awaken after few hours asleep, cloudy urine, hard to get back to sleep, coated tongue, bad breath, cold sweats often, bad dreams, color blind, bitter, metallic taste in mouth in AM, constipation, common, black or bloody stools, constipation, diarrhea –alternating, bleeding gums, convulsions, bloating of intestines, crave candy or coffee in afternoon, blurred vision, crave salt, blushes easily, crave sweets or snacks, body odor bad, crawling sensation of skin, bottle fed, cries easily/no apparent reason, bowel movements painful, cuts heal slowly, breathing irregular, damp weather bothers, brittle fingernails, dandruff, brown spot or bronzing of skin, dark glasses, bruise easily "black & blue spots", day dreamer, burning feet, daytime sleepiness, burning or itching anus, decreased amount of urin, burning on urination, decrease in appetite, burning stomach sensations, dental caries, relieved by eating, depressed, "butterfly" stomach, cramps, difficulty swallowing, dwell on past, digestion rapid, increased appetite, dizziness, eat often or get hunger pains or, drug reaction, Faintness, dull pain in chest or radiating to, eat rapidly, increase in weight, eat slowly, indigestion 1/2-1 hour after eating, eat when nervous, indigestion 3-4 hrs after eating, eyelids and face twitch, indoor occupation, eyelids swollen, puffy, smoky urine, eyes bulge, intestinal trouble, eyes or nose watery, intolerance to heat, eye strain, inward trembling, exhaustion-muscular and nervous, irritable and restless, extremities cold, clammy, irritable, annoyed easily, fainting spells, itching skin and feet, faintness if meals delayed, joint stiffness in evening, falling hair excessive, joint stiffness in morning, fatigue easily, keyed up, fail to calm, fatigue, eating relieves, lack energy, fearful, laxatives used often, fever easily raised, light colored stools, fluoridated toothpaste, loud talker, fluoridated water, loses temper easily, food poisoning history, low back pain, flank, frequent urination, low blood pressure, gag easily, lower bowel gas several hrs after eating, gas shortly after eating, magnifies insignificant events, get drowsy often, mentally alert, quick, going crazy sensation, mentally sluggish, goose flesh common, moods of depression, "blues" / melancholy, goose flesh seldom, mucous colitis, greasy food intolerances, muscle cramps, worse during exercise/ "charley horses", gum chewer, muscle-leg-toe cramps at night, hair coarse, falls out, muscle twitching, hair treatments, sprays, etc., nails weak, ridged, split, hallucinations, Nausea, hands and feet go to sleep easily, nerve pains, Numbness, nervousness, hand tremor, opens windows in closed room, hard to awaken, overeating sweets upset, hate to be criticized, overexertion reactions, headaches upon arising -wears off during the day, overwork, nose bleeds frequently, pain between shoulder blades, heart palpitates for no reason, perfectionist, hiccups frequently, perspiration increases, high altitude discomfort, perspiration decrease.

I hereby give my permission and consent that my case records may be used for research and educational purposes.

LIFE SCRIPT WORKSHEET
Describe Yourself