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.
Emergency contact person
Past health history:
Do you any allergies or are you sensitive to any drugs or substances?
What are your medical and surgical histories? (Including hospitalization, accidents and surgery)
Cancer: please specify (organ)
Metastasis to (organ):
Tobacco/ alcohol USE:
Do you drink alcohol? If yes, how much and how often?
How long ago & duration:
Do you smoke? If yes, how many cigarettes per day?
How long ago & duration:
Are you an ex-smoker? If yes, when did you quit?
Please describe your current state of health (location of the symptom, severity, duration and signs/symptoms)
Family History: how is the family’s health?
Perception and Health Management Pattern
Are you currently receiving treatment for any of these conditions?
If yes, please describe what kind of treatments, where and when?
Have you ever received radiation therapy?
Have you ever received chemotherapy? Please specify name of chemo drugs and how many cycles of chemotherapy Please specify:
Medical report (Attached)
CT scan (computerized tomography)
BLOOD RESULTS (For the last 3 months)
Current Medicine and supplement
Please list all of the following taken currently: all medications, hormone replacement therapies ,vitamins, minerals, herbals, supplements, protein powders
Name/Description, Dosage/Quantity, Frequency, REASON
Do you have any trouble taking medicines /supplements?
How often do you have the trouble?
(e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain
Have you had any recent changes in your weight that you are concerned about? If yes, please explain
Weight loss or gain? (amount)
Food intake / times a day
Fluid intake / liters of water per day
Do you find yourself eating processed foods often? (This includes red and packaged meats, frozen meals, and white bread but excludes homogenized milk and frozen veggies)
What is your diet menu? Please describe your daily meal(s)
Any food restriction regarding disease point of view?
Any food restriction regarding religious point of view?
What kind of food do you like?
What kind of food do you dislike?
Do you have any physical conditions that restrict food intake, such as mouth ulcers, difficulty swallowing?
How often do you have a bowel movement? (Describe) Frequency? Character? Discomfort? Problem in control?
If you take laxatives, what type/brand and how often?
Urinary elimination pattern? (Describe.) Frequency? Problem in control?
Describes patterns of sleep, rest, and relaxation
How many hours of sleep do you average a night?
Sleep onset problems? Dreams (nightmares)? Early awakening?
What do you feel after waking? (Fresh, headache, drowsy)
Are you using any medication for sleeping?
Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living
Activities of Daily Living (ADL)
In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet?
Instrumental Activities of Daily Living (ADL)
In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking your own medications?
Do you have any illnesses that affect to your movement such as tiredness or pain when moving, pain? please specify details:
How many times per week do you do stretching exercises to improve the flexibility of your back, neck, shoulders, and legs?
On those days that you engage in moderate to strenuous exercise, how many minutes on average do you exercise and what type of exercise?
Have you ever had any difficulty breathing? (This includes asthma, emphysema, chronic cough, pneumonia, Tuberculosis, or any other lung disorder)
Do you suffer from chronic pain? (2 months or more of continuous pain) Describe the symptom(s).
Where in the body does the symptom occur? Is there radiation or extension of the symptom(s) to another area of the body?
On a scale of 0-10, (10 being the worst) how bad is the symptom(s)?
What makes the symptom(s) better or worse?
Does it occur in association with something else (i.e., eating, exertion, movement)?
Does anything make it better?
What is your religion?
Do you pray, if so how long?
Please circle the number (0-10) that describes the best of your distress level over the weeks.
How often is stress a problem for you in handling? such things as: your health, your finances, your family or social relationships or your work
How often do you get the social and emotional support you need?
If you have stress, then what is your coping mechanism towards stress?
What makes you feel relaxed?
What makes you worry?
Do you believe that a regular holistic health routine will improve your lifestyle?
Tell me about your menstrual history (onset, length, amount of flow, cramps, bloating, PMS, age of first period, age of menopause).
Age at first menstrual period
First day of last normal menstrual period
Length of entire cycle / days
If yes, were your ovaries removed?
Last Pap Smear
History of abnormal pap smear?
If yes, when?
If you are human, leave this field blank.