First Time Evaluation

Complaints : Describe & Rate Severity on a scale of 1 -10 (ex. Migraines 8)

Diagnosed Medical Conditions : Describe & Date Of Onset (ex. Fibromyalgia 2008)

Medications: Name of Medication, Condition Taken For, Date Started (ex. Zoloft, Depression, 6/2002)

Surgeries (Operations, Traumas, Car Accidents, Age of Incident, Do you Have any surgical implants, Pins, Plates, Screws, Etc?

Dental Work (Crowns, Bridges, Root Canals, Fillings, Dentures,TMJ,Dental Surgeries, Any work needed or scheduled to be done

Stress Level on a scale of 1 to 10

Do you smoke? Amount? How long?

Recreational Drugs?

Exercise: (ex. Walk, 30 minutes, 4x a week)

Sunlight Exposure: Sunscreen (what kind) Minutes of Exposure

Sleep: Restful, Hard To Get To Sleep, Hard To Turn Off Brain, Wake Up Often, Bad Dreams, Vivid Dreams, other?

Digestion: Adequate, Poor, Acid Reflux, Burp,Bloat, Burning Pain In Stomach, Other?

Bowels: Bowel Elimination (1,2,3 times a day?) Consistency (Normal, hard, soft, diarrhea) Color? Other (Muscus, Gas, Smell)

arrow&v
Upload It