NEW PATIENT INFO & HEALTH HISTORY FORM

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SECTION 1

Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan. Please complete at least 24 hours prior to first visit. This will allow Dr. Henninger the chance to review your case and prepare for your visit.

Please be advised that you are providing information on an encrypted form that has a third party verification for standards (TRUSTe). Should this remain a concern please email us to arrange alternate means.

Thank you,
Dr. Maura Henninger

 

General Information
(MM/DD/YYYY)








Address


Contact Information





Emergency Contact



About you










Health Care Providers - Medical Doctor

Please name this provider and ensure their contact information is provided in this section.  



Add another Medical Doctor

Health Care Providers - Specialist

Please name this provider and ensure their contact information is provided in this section.  



Add another Specialist

Health Care Providers - Other

Please name this provider and ensure their contact information is provided in this section.  



Add another Health Care Provider

SECTION 2: REVIEW OF SYSTEMS


Allergies


Chief concerns












Mental/Emotional
Past Condition Current/Ongoing Condition Date of onset
Treated for emotional problems?
Depression?
Mood Swings?
Anxiety or nervousness?
Tension?
Poor Concentration?
Memory Problems?
Considered/attempted suicide?
Immune
Past Condition Current/Ongoing Condition Date of onset
Reactions to immunizations?
Reactions to vaccinations?
Chronic Fatigue Syndrome
Chronic infections?
Chronically swollen glands?
Slow wound healing?
Endocrine
Past Condition Current/Ongoing Condition Date of onset
Hypothyroid (low)?
Hyperthyroid (overactive)?
Hypoglycemia?
Diabetes?
Excessive thirst?
Excessive hunger?
Heat or cold intolerance?
Fatigue?
Seasonal depression?
Neurologic
Past Condition Current/Ongoing Condition Date of onset
Seizures
Muscle weakness?
Loss of memory?
Vertigo or dizziness?
Paralysis?
Numbness or tingling?
Easily stressed?
Loss of balance?
Skin
Past Condition Current/Ongoing Condition Date of onset
Rashes?
Acne/Boils?
Color changes?
Lumps?
Eczema/Hives?
Itching?
Perpetual Hair loss?
Night Sweats?
Head
Past Condition Current/Ongoing Condition Date of onset
Headaches?
Migraines?
Head Injury?
Ears
Past Condition Current/Ongoing Condition Date of onset
Impaired hearing?
Ringing in ears?
Dizziness?
Ear aches?
Eyes
Past Condition Current/Ongoing Condition Date of onset
Impaired vision?
Cataracts?
Glaucoma?
Spots in vision?
Color blindness?
Tearing or dryness?
Eye pain or strain?
Nose/Sinus
Past Condition Current/Ongoing Condition Date of onset
Frequent colds?
Sinus problems?
Nosebleeds?
Hayfever?
Loss of smell?
Neck
Past Condition Current/Ongoing Condition Date of onset
Lumps?
Difficulty swallowing?
Goiter?
Pain/Stiffness?
Mouth/Throat
Past Condition Current/Ongoing Condition Date of onset
Frequent sore throat?
Hoarseness?
Jaw clicks/TMJ?
Teeth grinding?
Gum problems?
Dental cavities?
Respiratory
Past Condition Current/Ongoing Condition Date of onset
Cough?
Sputum?
Asthma?
Wheezing?
Bronchitis?
Shortness of breath?
Pain with breathing?
Emphysema?
Tuberculosis?
Coughing up blood?
Gastrointestinal
Past Condition Current/Ongoing Condition Date of onset
Trouble swallowing?
Change in thirst?
Change in appetite?
Nausea/vomiting?
Hemorrhoids?
Heartburn?
Belching and/or passing gas?
Diarrhea?
Jaundice?
Gall bladder disease?
Liver disease?
Pancreatitis?
Abdominal pain or cramping?
Bloating?
Constipation?
Black stools?
Blood in stools?

  

*

Urinary
Past Condition Current/Ongoing Condition Date of onset
Increased frequency of urination?
Frequency at night?
Inability to hold urine?
Pain with urination?
Frequent Urinary Tract Infections?
Chronic kidney disease?
Kidney Stones?
Interstitial Cystitis?
Musculoskeletal
Past Condition Current/Ongoing Condition Date of onset
Joint Pain/Stiffness?
Weakness?
Muscle Spasms/Cramps?
Injury?
Broken bones?
Arthritis?
Osteoporosis/Osteopenia?
Blood
Past Condition Current/Ongoing Condition Date of onset
Anemia?
Easy bleeding or bruising?
Deep leg pain?
Thrombophlebitis?
Varicose veins?
Male Reproductive System
Past Condition Current/Ongoing Condition Date of onset
Hernias?
Testicular masses?
Testicular pain?
Benign Prostatic Hypertrophy ?
Are you sexually active?
Erectile Dysfunction?
Prostatitis?
Prostate Cancer?
Discharge or sores?
Sexually transmitted diseases?
Premature ejaculation?
Herpes?
Female Reproductive System

MM/DD/YYYY
days
days
MM/DD/YYYY

Past Condition Current/Ongoing Condition Date of onset
Cycles regular?
Painful menses?
Heavy flow?
Bleeding between cycles?
Sexually active?
Sexual difficulty?
Nipple discharge?
Endometriosis?
Fertility Issues?
PMS?
Ovarian cysts?
Cervical dysplasia?
Venereal diseases?
Abnormal pap?
Menopausal symptoms?
Tender breasts?
Breast lump(s)?

  










Hospitalization/Procedures

Please list any hospitalizations, surgeries, x-rays, CAT scans, MRI's, EEG's, EKG's or other procedures that you have have had.

YYYY
Add another procedure

SECTION 3: FAMILY HISTORY

Mother Father Sibling(s) Children Maternal Grand- mother Maternal Grand- father Paternal Grand- mother Paternal Grand- father
Select family members with known medical history
Cancers
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory Arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Auto Immune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies, sensitivities or intolerances
Environmental Sensitivities
Dementia
Parkinson's
ALS or other Motor Neuron Diseases
Genetic Disorders
Substance abuse (alcoholism, drugs)
Psychiatric Disorders
Depression
Schizophrenia
ADHD
Autism
Bipolar Disease

SECTION 4: LIFESTYLE

Nutrition History

















Exercise

Current Exercise Program:

Type Frequency per week Duration in minutes
Cardio/Aerobics
Strength
Mixed/Other




Tobacco

Alcohol intake






Other substances



Religious/Spiritual


Roles/Relationships






Unfortunately, abuse and violence of all kinds (verbal, emotional, physical and sexual) are leading contributors to chronic stress, illness and immune system dysfunction. Even witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes. Please do your best to answer the following questions: 








Sleep/Rest




Psychosocial








SECTION 5: CONTEXT OF CARE






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