History and Physical Exam Form

 

Name Birth date / /

Address

Home Phone

Work Phone

e-mail

Other Contact Information

Special Concerns

Occupation

Allergies to Medication

 

 

 

Main Health Concerns

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Health Goals

 

List Specific Health Goals

Hormone Balance

 

 

Pain Relief

 

 

Longevity/Prevention

 

 

Weight Loss

 

 

 

Exercise Enhancement

 

 

Anxiety/Depression/Stress Relief

 

 

Detoxification

 

 

Vitality Enhancement

 

 

Boost Immune Function

Allergy/Infection Relief

 

 

Improve Sexual Function

 

 

Improve Mental Functions

 

Reduce Substance Abuse

 

 

Inflammation Control

 

 

Metabolism Support

 

 

Infection Control

 

 

Sexual Enhancement

 

 

Deal with Cancer

 

 

Diabetes

Blood Sugar Control

 

 

Cardiovascular Health

 

Improve Lung Health

 

Improve Digestion

 

Increase Energy

 

Skin Health

 

Other Health Challenges or Goals

 

 

 

 

 

 

 

 

 

 


 

Priorities

 

What would you still like to accomplish in this lifetime?

1

 

2

 

3

 

4

 

5

 

 

 

 

What accomplishments are you most proud of?

1

 

2

 

3

 

4

 

5

 

 

 

 

What/Who is most important to you?

1

 

2

 

3

 

4

 

5

 

 


 

Past Medical/Surgical History

Condition

History

Active or Resolved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication and Supplement List

 

Medication or Supplement

Dosage

Why Taking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Family Medical History

 

Medical Condition

Self

Parents

Grandparents

Siblings

Other Relatives

Alcoholism

 

 

 

 

 

Anemia

 

 

 

 

 

Anesthesia problem

 

 

 

 

 

Arthritis

 

 

 

 

 

Asthma

 

 

 

 

 

Autoimmune disorder

 

 

 

 

 

Bleeding problem

 

 

 

 

 

Cancer, Breast

 

 

 

 

 

Cancer, Colon

 

 

 

 

 

Cancer, Melanoma

 

 

 

 

 

Cancer, Ovary

 

 

 

 

 

Cancer, Prostate

 

 

 

 

 

Heart Attack (Coronary Artery Disease)

 

 

 

 

 

Birth Defects

 

 

 

 

 

Depression

 

 

 

 

 

Diabetes, Type 1 (childhood onset)

 

 

 

 

 

Diabetes, Type 2 (adult onset)

 

 

 

 

 

Eczema

 

 

 

 

 

Food allergies

 

 

 

 

 

Other genetic diseases

 

 

 

 

 

Hay fever

 

 

 

 

 

Hearing problems

 

 

 

 

 

High cholesterol (Hyperlipidemia)

 

 

 

 

 

High Blood Pressure (Hypertension)

 

 

 

 

 

Immunosuppressive disorders

 

 

 

 

 

Kidney diseases

 

 

 

 

 

Mental retardation

 

 

 

 

 

Osteoporosis

 

 

 

 

 

Epilepsy (seizure disorder)

 

 

 

 

 

Stroke

 

 

 

 

 

Substance abuse

 

 

 

 

 

Thyroid disorders

 

 

 

 

 

Smoking

 

 

 

 

 

Tuberculosis

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Review of Systems

 

General Health Status

 

Healthy

 

Sickly

 

 

Strong

 

Weak

 

 

Hot

 

Cold

 

 

Dry

 

Damp

 

 

Extrovert

 

Introvert

 

 

In Excellent Shape

 

In Poor Shape

 

 

Happy

 

Depressed

 

 

Heal Fast

 

Heal Slow

 

 

Strong Disciplined

 

Weak Disciplined

 

 

Full of Energy

 

Easily Fatigued

 

 

Comfortable

 

Uncomfortable

 

 

Good Genes

 

Poor Genes

 

 

Enthusiastic

 

Lack-lustre

 

 

Athletic/Active

 

Couch Potato

 

 

Quick to Seek Help

 

Slow to Seek Help

 

 

Over-Achiever

 

Under-Achiever

 

 

Smart

 

Not So Smart

 

 

Talented

 

Not So Talented

 

 

Good Health Habits

 

Bad Health Habits

 

 

Loving

 

Selfish

 

 

Lovable

 

Not So Lovable

 

 

Honest

 

Not so Honest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Habits:

 

Tobacco Smoking History

Cigarettes per day x years Quit?

 

Alcohol History

Drinks per week x years Quit?

 

Marijuana smoking History

Joints per Day x years Quit?

 

IV Drug Use

Quit?

 

Other Drug Use

 

 

Frequent Unprotected Sex

 

 

Sexual Preference

 

 

Food Abuse

 

 

Gambling

 

 

 

 

 

 

 

 

 

 

 


Skin And Hair

 

Oily Skin

Hair loss

 

 

Dry Skin

Excess Hair Growth

 

 

Acne

Oily Hair

 

 

Rash

Dry Hair

 

 

Skin Depigmentation

Dandruff

 

 

Skin Cancer

Nail Thickening/discoloration

 

 

Draining skin wounds/skin ulcers

Body odor

 

 

Unusual Moles

Excess Sweating

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart and Blood Vessels

 

Chest Pain

 

 

 

Racing Heartbeat

Light-headed

 

 

Poor exercise tolerance

Pounding or in chest

 

 

Cramps in legs after walking

 

 

 

Cold Hands

 

 

 

Cold Feet

 

 

 

Discoloration of hands or feet

 

 

 

Varicose veins

 

 

 

Spider veins

 

 

 

Extremely slow heartbeat

 

 

 

Irregular heartbeat

 

 

 

Lungs and Respiration

 

Easily Short of Breath

Chronic Sinus Drainage with:

 

 

Wheezing

Clear Phlegm Production

 

 

Cough with:

Yellow Phlegm Production

 

 

Clear Phlegm Production

Green Phlegm Production

 

 

Yellow Phlegm Production

Blood in Mucous

 

 

Green Phlegm Production

 

 

 

Blood in Mucous

 

 

 

Fluid in Lungs

 

 

 

Pain on Breathing

 

 

 

 

 

 

 

 

 

 

 

Gastro-intestinal and Digestion

 

Abdominal Pain

Loose Stools: # BMs/day:

 

 

Heartburn or reflux

Not well formed

 

 

Frequent Burping

Watery Diarrhea

 

 

Frequent Farting

Blood in Stool

 

 

Bloating

Mucous in Stool

 

 

Indigestion

Stinky

 

 

Constipation: # BMs/week:

 

 

 

Difficulty swallowing at times

 

 

 

Hemorrhoids

 

 

 

Chronic nausea

 

 

 

 

 

 

 

 

 

 

 

 

Genital-urinary

 

Frequent Urination

Dryness in vaginal area

 

 

# times awaken to pee at night:

Pain on intercourse

 

 

Burning on urination

Abnormal vaginal/penile discharge

 

 

Difficulty starting urine stream

Unusual growths in genital areas

 

 

Blood in urine

Difficulty getting/maintaining erection

 

 

Pelvic or groin pain

Low sex drive

 

 

Pain in kidney area

Difficulty achieving orgasm

 

 

Pain or unusual mass in scrotum

High Sex Drive

 

 

 

Premature orgasms

 

 

 

Hot flashes or night sweats

 

 

 

 

 

 

 

Immunity

 

# respiratory infections/year:

 

 

 

Difficulty fighting of infections

 

 

 

Respiratory allergies / hayfever

 

 

 

Generally immune deficient

 

 

 

Autoimmune problems

 

 

 

Highly vulnerable to the wind

 

 

 

 

 

 

 

 

 

 

 

 

Nervous System/Sense organs

 

Blurred vision

Difficulty falling asleep

 

 

Double vision

# times awake up at night:

 

 

Hard of hearing

#headaches per week:

 

 

Vertigo (spins)

Throbbing

 

 

Ringing in ear (tinnitus)

One sided

 

 

Numbness in hands

Behind eye

 

 

Numbness in legs

Back of Head

 

 

Tremors or hand-shaking

Sinus Area

 

 

Fall of balance easily

Top of Head

 

 

Poor sense of smell

Muscle twitching

 

 

Poor memory

Weakness

 

 

Psycho-spiritual System

 

Chronic Depression

Delusional

 

 

Generally Anxious

Anorectic/bulimic

 

 

Obsessive/compulsive

Lonely

 

 

Panic attacks

Apathetic

 

 

Phobias:

Atheist

 

 

Substance abuse:

Agnostic

 

 

Cynical / hopeless

Orthodox/Fundamentalist

 

 

Hear uncomfortable voices

Difficulty with intimate relationships

 

 

Strong religious/spiritual beliefs

Trouble concentrating

 

 

Feel spiritually empty

Frequently angry, Bad temper

 

 

Unclear of life purpose

Stressed out

 

 

 

 

 

 

 

 

 

Musculoskeletal System

 

Neck pain

Ankle pain

 

 

Upper back pain

Foot pain

 

 

Shoulder pain

Generalized muscle pain

 

 

Elbow pain

Other pain:

 

 

Wrist pain

 

 

 

Hand/finger pain

 

 

 

Mid-back pain

 

 

 

Low back pain

Joint swelling/stiffness:

 

 

Rib Pain

 

 

 

Hip pain

 

 

 

Knee Pain

 

 

 

 

 

 

 

 

Religion/spiritual belief

 

 

 

 

 

 

Healing Philosophy

 

 

 

 


Constitution

General

Yin

Strong

Hot

Damp

 

Yang

Deficient

Cold

Dry

 

Body Type

Endomorph

Mesomorph

Ectomorph

Dosha

Vata

Pitta

Kapha

Pitta-Vata

Kapha-Pitta

Pitta-Kapha

Kapha-Vata

Vata-Pitta

Vata-Kapha

Vata-Pitta-Kapha

Gunas

Sattwic

Rajasic

Tamasic

Predominant

Constitutional

Element

Fire

Earth

Metal

Water

Wood

Introvert

Extrovert

Thinking

Feeling

Sensing

Intuitive

Aggressive

Passive

Rigid

Flexible

 

 

 

 

 

 


Physical Exam

 

Vital Signs

Temperature

Oral:

 

Axillary:

 

Aural:

 

Anal:

 

Basal Body Temperature:

 

 

Blood Pressure:

 

Resting Supine Blood Pressure:

 

Standing Blood Pressure:

 

Peak Exercise Blood Pressure:

 

Respiration

 

Rate

 

Rhythm

 

Depth

 

Superficial

Middle

Full

Clavicular Breathing

 

Abdominal Breathing

 

Long

Slow

Hard

Soft

Smooth

Choppy

 

Pulse

Rate

 

 

Yang

Excess

Hot

Superficial

Rhythm

 

 

Yin

Deficient

Cold

Interior

Pulse Dosha

Vata

Pitta

Kapha

Position

 

Upper

Middle

Lower

Left

S

 

 

 

M

 

 

 

D

 

 

 

Right

 

S

 

 

 

M

 

 

 

D

 

 

 

Floating

Hollow

Flooding

Slippery

Wiry

Tight

Excessive

Submerged

Thin

Minute

Choppy

Soft

Frail

Scattered

Deep

 

 

 

 

 

 


 

Exam

Head

 

 

Eyes

 

Pupils

Extra-ocular muscles

Fundi

Iris

Ears

 

 

Nose

 

 

Throat

 

 

Teeth

 

 

Gums

 

 

Tongue

 

Body Color

 

Body Shape

 

Coating Color

 

Coating Thickness

 

Coating Distribution

 

Moisture

 

Coating Root

 

Spirit

 

Crack, fissures ,burns

 

Cranial Nerves

 

 

Facial Skin

 

 

Complexion

 

 

Jaw

 

 

Lips

 

 

Neck

 

 

Lymph Nodes

 

Scalp and Sutures

 

 

Temporal Artery

 

 

Sinuses

 

 

Voice

soft

loud

rough

sweet

pressured

Throat

 

 

 

Hair

 

 

 

 

 

 

 

Thorax

Heart

 

Lungs

 

Ribs

 

Sternum

 

Thoracic Spine

 

Alarm Points

 

Skin

 

 

 

 

 

 

 

Abdomen

Diaphragm

 

 

Solar Plexus

 

 

Right upper Quadrant

 

Mid-Epigastrium

 

Left Upper Quadrant

 

Left Lower Quandrant

 

Right Upper Quadrant

 

Umbilical Area

 

 

Supra-pubic Area

 

Inguinal Area

 

 

Genitals

 

Pelvis

 

Rectum

 

Prostate

 

Hara

 

Alarm Points

 

 

Waist

 

Skin

 

 

 

 

 

 

 

 

Extremities

Shoulders

 

Arm Alarm Points

 

Hands

 

Fingers

 

Wrists

 

Elbows

 

Forearm

 

Fingernails

 

Arm Neuro

Strength & ROM

 

 

Hips

 

Knees

 

Ankles

 

Foot

 

Toes

 

Toe Nails

 

Leg Alarm Points

 

Leg Neuro

Strength & ROM

 

 

 

Alarm Points

Lung 1

Lung

 

CV-12

Stomach

 

CV-14

Heart

 

CV-17

Pericardium

 

Liv-13

Spleen

 

Liv14

Liver

 

GB-24

Gallbladder

 

GB-25

Kidney

 

Stomach 25

Large Intestine

 

CV-5

Triple Warmer

 

CV-4

Small Intestine

 

CV-3

Bladder

 

 

 

 

 


 

 

TCM Internal Organs

Organ

Qi

Blood

Excess

Weak

Rebel

Prolapse

Stagna-tion

Heat

Cold

Deficiency

Stagnation

Heart

Pericardium

Small Intestine

 

 

 

 

 

 

 

 

 

Spleen

Stomach

 

 

 

 

 

 

 

 

 

Lung

Large Intestine

 

 

 

 

 

 

 

 

 

Kidney

Bladder

 

 

 

 

 

 

 

 

 

Liver

Gallbladder

 

 

 

 

 

 

 

 

 

Pericardium

Triple Warmer

 

 

 

 

 

 

 

 

 

 


 

 

Tender Back Points

Vertebra

Bladder

Point

Organ

Nervous System

Left Side

Right Side

T-1

11

sea of blood

Hands, thyroid

 

 

T-2

12

wind gate

Heart

 

 

T-3

13

lung

Lungs, bronchi, pleura, chest

 

 

T-4

14

pericardium

Gallbladder,

Common Duct

 

 

T-5

15

heart

Liver, solar plexus

 

 

T-6

16

governor

Stomach,

Mid-back

 

 

T-7

17

diaphragm

Pancreas,

duodenum

 

 

T-8

extra

 

Spleen, low mid back

 

 

T-9

18

liver

Adrenal Glands

 

 

T-10

19

gallbladder

Kidneys

 

 

T-11

20

spleen

Ureters

 

 

T-12

21

stomach

Small Intestine, upper-low back

 

 

L-1

22

triple burner

Iliocecal valve, large intestine

 

 

L-2

23

kidney

Appendix, abdomen, upper leg

 

 

L-3

24

sea of qi

Sex organs, uterus, bladder knees

 

 

L-4

25

large intestine

Prostate, lower back

 

 

L-5

26

gate of origin

Sciatic, lateral leg and feet

 

 

Sacrum

27 28 29 30

Small intestine

Bladder

Hip, buttocks, rectum, anus

 

 

Piriformis

GB 30

 

Sciatic nerve

 

 

 

GB-20

 

 

 

 

 

GB-21

 

 

 

 

 

Bl-10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Screening Guidelines for Non-risk, Healthy Adults

Evaluation

Guidelines- Non-risk, Healthy Adults

Dates Performed

Physical Health Exam

Periodically

 

 

 

 

 

Cholesterol Screening

Every 5 years. Men beginning at age 35, Women at age 45.

 

 

 

 

 

Pap Smear (F)

Every 1-3 years to age 65

 

 

 

 

 

Mammogram (F)

Every 1-2 years, over age 49

 

 

 

 

 

Breast exam (F)

Every 1-2 years

 

 

 

 

 

PSA (M)

At clinician's discretion

 

 

 

 

 

Sigmoidoscopy

Every 3-5 years after age 19

 

 

 

 

 

Glaucoma

Blacks - ages 20-45 every 3-5 years
Whites - baseline at ages 35-45
All races - over 50 every 3-5 years

 

 

 

 

 

Vision

Every 2-5 years after age 40

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vaccinations

Vaccine

Dates Performed

Influenza

 

 

 

 

 

 

Pneumovax

 

 

 

 

 

 

Td

 

 

 

 

 

 

Hepatitis B

 

 

 

 

 

 

Hepatitis A

 

 

 

 

 

 

MMR

 

 

 

 

 

 

Varicella

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ranges of Personal Discipline Styles

Strong willed

Lazy

Perfectionist

Sloppy

Self-promoting

Self-defeating

Orderly

Haphazard

All-or-nothing

Little bit bitter than none

Obsessive-compulsive

Go with the flow

Patient--Not easily frustrated

Impatient--Easily frustrated

Not easily distracted

Easily distracted

Strong ego

Weak ego

Deep vision

Short-sighted

Clear minded

Foggy minded

Gentle

Heavy handed

Encouraging

Fear-based

Flexible

Inflexible

Deep vision

Short-sighted

Reason based

Traditional

 

 

Common Self-Defeating Attitudes and Behaviors And Their Solutions

Procrastination

Well-Paced

Fear of Rejection or Failure

Encouraged and Secure

Perfectionism

The Best Feasibly Capable

Low Self Esteem

Self-Respect

Cynicism and a Sense of Hopelessness

Hopeful

Pride

Willing to Take the Chance of Looking Foolish to Succeed

Helplessness

Willing to Try

Self-righteousness

Open Minded and Flexible

Martyrdom

Approach even the Sufferings of Life with Appreciation

 

 

Hindrances on the Path and Solutions

Sickness

Vitality

Dullness

Sharpness

Doubt

Conviction

Carelessness

Carefulness

Laziness

Disciplined

Attachment

Detachment

Lack of True Understanding

Right Knowledge

Inattentiveness

Focused

Compulsive

Steadfastness


 

Test Ordered

Results

Reported

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Date


Problem List

 

Problem

Strategy to Resolution

Resolved