Eleanor P. Womack, MD

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Eleanor P. Womack, MD

Kayla McElhany, RN, FNP-C

Heather Beavers, RN, FNP-C

ADULT MEDICAL QUESTIONNAIRE

First Name: __________________________ Middle Name: _____________________ Last Name: __________________________ Address:______________________________________________ City: _____________________ State: _______ ZIP: _____________ Home Phone: (__________) __________-_____________ Birth Date: ________ /________ /_________ Age: __________

month day year

Cell Phone: (__________) __________-_____________ E-mail: ______________________________________________

Place of Birth:____________________________________________ Occupation: ___________________________________________

Referred by:____________________________________ Height: _______′ _______ ″ Weight: _________ Sex: ________

Today’s Date _________________ Emergency Contact: ________________________________ Ph: ______________________ Pharmacy of choice: ________________________________________ Location: __________________________________________ Compounding pharmacy of choice: ______________________________________ Location: ____________________________

1. Allergies to Environment/Food/Medications: ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ _____________________________________________

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Medications/Supplements I Take:

Product Name

Strength

Directions

Example: Fish Oil

1000 mg

once daily

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1. Please rank current and ongoing problems by priority and fill in the other boxes as completely as possible:

DESCRIBE PROBLEM

MILD/ MODERATE/

SEVERE TREATMENT APPROACH SUCCESS Example: Post Nasal Drip Moderate Elimination Diet Moderate a. b. c. d. e. f. g.

2. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister

________________________________________________________________________________________ ________________________________________________________________________________________

3. Have you ever lived or traveled outside of the United States? Yes _________ No ________ If so, when and where?

________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 4. Past Medical and Surgical History:

ILLNESSES

WHEN

COMMENTS

a. Anemia b. Arthritis c. Asthma d. Bronchitis e. Cancer

f. Chronic Fatigue Syndrome

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h. Diabetes i. Emphysema

j. Epilepsy, convulsions, or seizures k. Gallstones

l. Gout

ILLNESSES

WHEN

COMMENTS

m. Heart attack/Angina n. Heart failure

o. Hepatitis

p. High blood fats (cholesterol, triglycerides) q. High blood pressure (hypertension) r. Irritable bowel s. Kidney stones t. Mononucleosis u. Pneumonia v. Rheumatic fever w. Sinusitis x. Sleep apnea y. Stroke z. Thyroid disease aa. Other (describe)

INJURIES

WHEN

COMMENTS

ab. Back injury

ac. Broken Bone (describe) ad. Head injury

ae. Neck injury af.

Other

(describe)

DIAGNOSTIC STUDIES

WHEN

COMMENTS

ag. Barium Enema ah. Bone Scan

ai. CAT Scan of Abdomen aj. CAT Scan of Brain ak. CAT Scan of Spine al. Chest X-ray am. Colonoscopy an. EKG

ao. Liver scan ap. Neck X-ray aq. NMR/MRI

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ar. Sigmoidoscopy as. Upper GI Series at. Other (describe)

OPERATIONS

WHEN

COMMENTS

au. Appendectomy av. Dental Surgery aw. Gall Bladder ax. Hernia ay. Hysterectomy az. Tonsillectomy ba. Other (describe) bb. Other (describe) 5. Hospitalizations:

WHERE HOSPITALIZED

WHEN

FOR WHAT REASON

a. b. c. d. e.

6. Have you ever used alcohol? Yes__________ No__________ a. If yes, how often do you now drink alcohol?

_____ No longer drinking alcohol _____ Average 1-3 drinks per week _____ Average 4-6 drinks per week _____ Average 7-10 drinks per week _____ Average >10 drinks per week c. Have you ever had a problem with alcohol? Yes__________ No___________

d. If yes, please indicate time period (month/year): From _____________ To ______________. 7. Have you ever used recreational drugs? Yes__________ No__________

8. Have you ever used tobacco? Yes__________ No__________ If yes:

a. Number of years as a nicotine user: _____________. b. Amount per day _____________.

c. Year quit _____________.

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9. Are you exposed to second hand smoke regularly? Yes_________ No__________

10.

Family History:

Stroke Heart

Disease Blood High Pressure

Diabetes Thyroid

Disease Cancer Cause: Age of Death

Mother

Father

Sibling

Paternal

Grandfather

Paternal Grandmother Maternal Grandfather Maternal Grandmother

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How well have things been going for you?

Very Well Fair Poorly Very

Poorly Does not apply a. At school

b. In your job c. In your social life d. With close friends e. With sex

f. With your attitude

g. With your boyfriend/girlfriend h. With your children

i. With your parents j. With your spouse

12. Are you currently, or have you ever been, married? Yes_________ No__________ If so:

a. When were you married? _________________ b. Spouse's occupation: __________________

c. When were you separated: __________________ Never ______________ d. When were you divorced? __________________ Never ______________ e. When were you remarried? ___________________ Never ______________ f. Spouse’s occupation __________________

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Comments: ______________________________________________________________________________________________

FOR WOMEN ONLY

1. Have you ever been pregnant? Yes_______ No_______

Number of miscarriages _______ Number of abortions _______ Number of preemies _______ Number of term births _______ Birth weight of largest baby _______ Smallest baby _______ Did you develop toxemia (high blood pressure)? Yes________ No________

Have you had other problems with pregnancy? Yes________ No________

If so, please comment: ___________________________________________________ ________________________________________________________________________ 2. Age at first period _________ Date of last Pap Smear __________ Date of last Mammogram____________

Pap Smear: ______ Normal ______ Abnormal Mammogram: _______ Normal ______ Abnormal Date of last period _________

3. Have you ever used birth control pills? Yes_______ No_______ If yes, when __________________ 4. Are you taking the pill now? Yes_______ No_______

5. Did taking the pill agree with you? Yes_______ No_______ Not applicable _______ 6. Do you currently use contraception? Yes_______ No_______

If yes, what type of contraception do you use? _______________________________________________ 7. Are you in menopause? No _____ Yes _____ If yes, age at last period______

Do you take: Estrogen?___ Ogen?___ Estrace?___ Premarin?___ Other (specify)___________ Progesterone?___ Provera? ___ Other (specify) _______________

8. How long have you been on hormone replacement therapy (if applicable)? _______________________

9. In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or

irritability (PMS)?

Yes No Not applicable __

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Medical Symptoms Questionnaire

Rate each of the following symptoms based upon your typical health profile for the past 30 days.

Point Scale:

0¶ Never or almost never have the symptom

1¶ Occasionally have it, effect is not severe

2¶ Occasionally have it, effect is severe

3¶ Frequently have it, effect is not severe

4¶ Frequently have it, effect is severe

Head

________ Headaches

________ Faintness

________ Dizziness

________ Insomnia

Total __________

Eyes

________ Watery or itchy eyes

________ Swollen, reddened or sticky eyelids

________ Bags or dark circles under eyes

________ Blurred or tunnel vision

(Does not include enar or far-sightedness)

Total __________

Ears

________ Itchy ears

________ Earaches, ear infections

________ Drainage from ear

________ Ringing in ears, hearing loss

Total __________

Nose

________ Stuffy nose

________ Sinus problems

________ Hay fever

________ Sneezing attacks

________ Excessive mucus formation

Total __________

Mouth/Throat

________ Chronic coughing

________Gagging, frequent need to clear throat

________ Sore throat, hoarseness, loss of voice

________ Swollen or discolored tongue, gums, lips

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5656 Bee Caves Road Suite E-200 Austin Texas 78746 Phone 512-327-8700 Fax 512-327-8701

Skin

________ Acne

________ Hives, rashes, dry skin ________ Hair loss

________ Flushing, hot flashes

________ Excessive sweating Total __________ Heart

________ Irregular or skipped heartbeat ________ Rapid or pounding heartbeat

________ Chest pain Total __________ Lungs

________ Chest congestions ________ Asthma, bronchitis ________ Shortness of breath

________ Difficulty breathing Total __________ Digestive Tract

________ Nausea, vomiting ________ Diarrhea

________ Constipation ________ Bloated feeling ________ Belching, passing gas ________ Heartburn

________ Intestinal/stomach pain Total __________ Joints/Muscle

________ Pain or aches in joints ________ Arthritis

________ Stiffness or limitation of movement ________ Pain or aches in muscles

________ Feeling of weakness or tiredness Total __________ Weight

________ Binge eating/drinking ________ Craving certain foods ________ Excessive weight ________ Compulsive eating ________ Water retention ________ Underweight Total __________ Energy/Activity ________ Fatigue, sluggishness ________ Apathy, lethargy ________ Hyperactivity ________ Restlessness Total __________

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5656 Bee Caves Road Suite E-200 Austin Texas 78746 Phone 512-327-8700 Fax 512-327-8701

Mind

________ Poor memory

________ Confusion, poor comprehension ________ Poor concentration

________ Poor physical coordination ________ Difficulty making decisions ________ Stuttering or stammering ________ Slurred speech

________ Learning disabilities Total __________ Emotions

________ Mood swings

________ Anxiety, fear, nervousness ________ Anger, irritability, aggressivness

________ Depression Total __________ Other

________ Frequent illness

________ Frequent or urgent urination

________ Genital itch or discharge Total __________

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Eleanor P. Womack, MD