7.
Please list all
serious accidents,
surgeries or hospitalizations:
Month/Year Reason
& Results
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
8.
Please list pertinent
medical/psychological
tests done in
the past that
relate
to the present
problem and bring
them to your appointment
if they are available:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
9.
Please describe
any behaviour
problems (if applicable):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
10. Please describe
any sexual problems
(if applicable):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
11.
Please describe
any birth complications
(if applicable):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
12.
How long has it
been since the
patient was totally
well? _______________
13.
List your main
goals as far as
the patient’s
health is concerned?
________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
14.
Has the patient
had any alternative
medical treatment
(acupuncture,
naturopathy, herbal
medicine, homeopathy,
etc.) before?
Please provide
details
and/or results
achieved:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
15.
List all medications
including medical
drugs, homeopathic
remedies, herbal
remedies,
vitamins, supplements,
etc., that the
patient is currently
taking.
List the
reasons the patient
is taking them
(if known), the
dosage and the
frequency.____________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
16.
If seizures are
a problem, please
provide the following
information:
Date
of the first seizure:
__________________________________________
Frequency
of seizures: ___________________________________________
How
many seizures
have occurred
in the last 6
months: _________________
What
is the average
duration of a
seizure(s): __________________________
Describe
a typical seizure
(provide as much
detail as possible):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
17.
List the patient’s
educational experience
and/or qualifications.
List schools
attended and grades
attained:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What
kind of assistance
does the patient
receive at school/work?
_____________________________________________________________
List
any problems that
the patient may
be experiencing
at school/work:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
18. What does
the patient do
for recreation?
What are the main
interests and
hobbies?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
19.
Does the patient
take vacations
regularly? No
________ Yes ________
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