Patient Assessment

THIS IS A CONFIDENTIAL QUESTIONNAIRE TO HELP US DETERMINE THE BEST TREATMENT PLAN FOR YOU. PLEASE FILL IT OUT AS COMPLETELY AS POSSIBLE. THANK YOU.

GENERAL INFORMATION

Past health history


Tobacco/ alcohol USE

PRESENT HEALTH

Perception and Health Management Pattern

Medical report (Attached)


Current Medicine and supplement

Name/Description, Dosage/Quantity, Frequency, REASON

Nutritional Assessment

(e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain

ELIMINATION PATTERN

SLEEP-REST PATTERN

Describes patterns of sleep, rest, and relaxation

ACTIVITY-EXERCISE PATTERN

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living

Respiratory

PAIN

Value-Belief Pattern

FOR WOMEN

Tell me about your menstrual history (onset, length, amount of flow, cramps, bloating, PMS, age of first period, age of menopause).

CONTACT US

Akesis Life Clinic

21 Fl., 253 Asoke Building,

Sukhumvit 21 Road, Klongtoey-Nua,

Wattana, Bangkok 10110

Office Hours

Monday - Saturday, 9.00 AM - 6.00 PM