History and Physical Exam Form
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Address |
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Home
Phone |
Work
Phone |
e-mail |
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Other
Contact Information |
Special
Concerns |
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Occupation |
Allergies
to Medication |
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Main
Health Concerns |
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Health Goals
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List Specific
Health Goals
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Hormone
Balance |
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Pain
Relief |
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Longevity/Prevention |
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Weight Loss
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Exercise
Enhancement |
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Anxiety/Depression/Stress Relief
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Detoxification |
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Vitality
Enhancement |
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Boost
Immune Function Allergy/Infection
Relief |
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Improve
Sexual Function |
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Improve
Mental Functions |
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Reduce
Substance Abuse |
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Inflammation
Control |
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Metabolism
Support |
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Infection
Control |
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Sexual
Enhancement |
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Deal
with Cancer |
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Diabetes
Blood
Sugar Control |
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Cardiovascular
Health |
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Improve
Lung Health |
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Improve Digestion |
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Increase
Energy |
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Skin
Health |
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Other Health Challenges or Goals |
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Priorities
What would you still like to
accomplish in this lifetime?
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1 |
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2 |
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3 |
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4 |
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5 |
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What accomplishments are you most
proud of?
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1 |
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2 |
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3 |
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4 |
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5 |
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What/Who is most important to you?
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2 |
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3 |
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4 |
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5 |
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Past Medical/Surgical
History
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Condition |
History
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Active or
Resolved |
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Medication and Supplement List
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Medication or Supplement |
Dosage |
Why Taking |
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Family Medical History
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Medical Condition |
Self |
Parents |
Grandparents |
Siblings |
Other
Relatives |
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Alcoholism |
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Anemia |
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Anesthesia problem |
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Arthritis |
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Asthma |
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Autoimmune disorder |
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Bleeding problem |
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Cancer, Breast |
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Cancer, |
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Cancer, Melanoma |
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Cancer, Ovary |
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Cancer, Prostate |
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Heart Attack (Coronary Artery Disease) |
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Birth Defects |
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Depression |
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Diabetes, Type 1 (childhood onset) |
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Diabetes, Type 2 (adult onset) |
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Eczema |
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Food allergies |
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Other genetic diseases |
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Hay fever |
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Hearing problems |
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High cholesterol (Hyperlipidemia) |
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High Blood Pressure (Hypertension) |
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Immunosuppressive disorders |
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Kidney diseases |
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Mental retardation |
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Osteoporosis |
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Epilepsy (seizure disorder) |
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Stroke |
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Substance abuse |
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Thyroid disorders |
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Smoking |
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Tuberculosis |
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Other: |
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Review of Systems
General Health Status
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Healthy |
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Sickly
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Strong |
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Weak
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Hot |
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Cold |
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Dry |
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Damp |
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Extrovert |
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Introvert |
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In
Excellent Shape |
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In Poor Shape |
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Happy |
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Depressed |
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Heal
Fast |
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Heal Slow |
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Strong
Disciplined |
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Weak Disciplined |
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Full
of Energy |
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Easily Fatigued |
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Comfortable |
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Uncomfortable |
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Good
Genes |
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Poor Genes |
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Enthusiastic |
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Lack-lustre |
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Athletic/Active |
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Couch Potato |
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Quick
to Seek Help |
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Slow to Seek Help |
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Over-Achiever |
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Under-Achiever |
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Smart |
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Not So Smart |
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Talented |
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Not So Talented |
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Good
Health Habits |
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Bad Health Habits |
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Loving |
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Selfish |
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Lovable |
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Not So Lovable |
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Honest |
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Not so Honest |
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Other
Habits:
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Tobacco Smoking History |
Cigarettes per day x years Quit? |
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Alcohol History |
Drinks per week x years
Quit? |
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Marijuana smoking History |
Joints per Day x
years
Quit? |
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IV Drug Use |
Quit? |
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Other Drug Use |
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Frequent Unprotected Sex |
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Sexual Preference |
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Food Abuse |
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Gambling |
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Skin And Hair
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Oily Skin |
Hair loss |
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Dry Skin |
Excess Hair Growth |
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Acne |
Oily Hair |
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Rash |
Dry Hair |
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Skin Depigmentation |
Dandruff |
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Skin Cancer |
Nail
Thickening/discoloration |
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Draining skin wounds/skin ulcers |
Body odor |
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Unusual Moles |
Excess Sweating |
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Heart and Blood Vessels
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Chest Pain |
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Racing Heartbeat |
Light-headed |
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Poor exercise tolerance |
Pounding or in chest |
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Cramps in legs after walking |
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Cold Hands |
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Cold Feet |
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Discoloration of hands or feet |
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Varicose veins |
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Spider veins |
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Extremely slow heartbeat |
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Irregular heartbeat |
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Lungs and Respiration
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Easily Short of Breath |
Chronic Sinus Drainage with: |
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Wheezing |
Clear Phlegm Production
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Cough with: |
Yellow Phlegm
Production |
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Clear Phlegm
Production |
Green Phlegm
Production |
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Yellow Phlegm
Production |
Blood in Mucous |
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Green Phlegm
Production |
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Blood in Mucous |
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Fluid in Lungs |
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Pain on Breathing |
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Gastro-intestinal and Digestion
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Abdominal Pain |
Loose Stools:
# BM’s/day: |
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Heartburn or reflux |
Not well formed |
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Frequent Burping |
Watery Diarrhea |
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Frequent Farting |
Blood in Stool |
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Bloating |
Mucous in Stool |
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Indigestion |
Stinky |
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Constipation: #
BM’s/week: |
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Difficulty swallowing at times |
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Hemorrhoids |
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Chronic nausea |
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Genital-urinary
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Frequent Urination |
Dryness in vaginal
area |
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# times awaken to pee at night: |
Pain on intercourse |
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Burning on urination |
Abnormal vaginal/penile
discharge |
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Difficulty starting urine stream |
Unusual growths in
genital areas |
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Blood in urine |
Difficulty
getting/maintaining erection |
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Pelvic or groin
pain |
Low sex drive |
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Pain in kidney area |
Difficulty achieving
orgasm |
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Pain or unusual mass in scrotum |
High |
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Premature orgasms |
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Hot flashes or night
sweats |
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Immunity
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# respiratory infections/year: |
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Difficulty fighting of infections |
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Respiratory allergies / hayfever |
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Generally immune deficient |
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Autoimmune problems |
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Highly vulnerable to the wind |
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Nervous System/Sense organs
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Blurred vision |
Difficulty falling asleep |
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Double vision |
# times awake up at night: |
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Hard of hearing |
#headaches per week:
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Vertigo (spins) |
Throbbing |
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Ringing in ear (tinnitus) |
One sided |
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Numbness in hands |
Behind eye |
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Numbness in legs |
Back of
Head |
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Tremors or hand-shaking |
Sinus Area |
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Fall of balance easily |
Top of Head |
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Poor sense of smell |
Muscle twitching |
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Poor memory |
Weakness |
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Psycho-spiritual System
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Chronic Depression |
Delusional |
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Generally Anxious |
Anorectic/bulimic |
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Obsessive/compulsive |
Lonely |
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Panic attacks |
Apathetic |
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Phobias: |
Atheist |
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Substance abuse: |
Agnostic |
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Cynical / hopeless |
Orthodox/Fundamentalist |
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Hear uncomfortable voices |
Difficulty with intimate
relationships |
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Strong religious/spiritual beliefs |
Trouble concentrating |
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Feel spiritually empty |
Frequently angry, Bad
temper |
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Unclear of life purpose |
Stressed out |
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Musculoskeletal System
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Neck pain |
Ankle pain |
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Upper back pain |
Foot pain |
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Shoulder pain |
Generalized muscle
pain |
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Elbow pain |
Other pain: |
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Wrist pain |
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Hand/finger pain |
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Mid-back pain |
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Low back pain |
Joint swelling/stiffness: |
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Rib Pain |
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Hip pain |
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Knee Pain |
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Religion/spiritual belief |
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Healing Philosophy |
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Constitution
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General |
Yin |
Strong |
Hot |
Damp |
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Yang |
Deficient |
Cold |
Dry |
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Body Type |
Endomorph |
Mesomorph |
Ectomorph |
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Dosha |
Vata
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Pitta |
Kapha |
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Pitta-Vata |
Kapha-Pitta |
Pitta-Kapha |
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Kapha-Vata |
Vata-Pitta |
Vata-Kapha |
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Vata-Pitta-Kapha |
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Gunas |
Sattwic |
Rajasic |
Tamasic |
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Predominant Constitutional Element |
Fire |
Earth |
Metal |
Water |
Wood |
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Introvert |
Extrovert |
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Thinking |
Feeling |
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Sensing |
Intuitive |
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Aggressive |
Passive |
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Rigid |
Flexible |
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Physical Exam
Vital Signs
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Temperature |
Oral: |
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Axillary: |
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Aural: |
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Anal: |
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Basal Body Temperature: |
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Blood Pressure: |
Resting Supine Blood Pressure: |
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Standing Blood Pressure: |
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Peak Exercise Blood Pressure: |
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Respiration |
Rate |
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Rhythm |
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Depth |
Superficial |
Middle |
Full |
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Clavicular Breathing |
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Abdominal Breathing |
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Long |
Slow |
Hard |
Soft |
Smooth |
Choppy |
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Pulse |
Rate |
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Yang |
Excess |
Hot |
Superficial |
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Rhythm |
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Yin |
Deficient |
Cold |
Interior |
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Pulse Dosha |
Vata |
Pitta |
Kapha |
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Position |
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Upper |
Middle |
Lower |
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Left |
S |
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M |
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D |
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Right |
S |
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M |
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D |
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Floating |
Hollow |
Flooding |
Slippery |
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Wiry |
Tight |
Excessive |
Submerged |
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Thin |
Minute |
Choppy |
Soft |
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Frail |
Scattered |
Deep |
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Exam
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Head |
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Eyes |
Pupils Extra-ocular
muscles Fundi Iris |
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Ears |
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Nose |
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Throat |
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Teeth |
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Gums |
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Tongue |
Body
Color |
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Body
Shape |
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Coating
Color |
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Coating
Thickness |
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Coating
Distribution |
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Moisture |
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Coating
Root |
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Spirit |
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Crack,
fissures ,burns |
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Cranial
Nerves |
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Facial
Skin |
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Complexion |
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Jaw |
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Lips |
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Neck |
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Lymph
Nodes |
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Scalp
and Sutures |
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Temporal
Artery |
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Sinuses |
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Voice |
soft |
loud |
rough |
sweet |
pressured |
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Throat
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Hair |
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Thorax |
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Heart |
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Lungs |
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Ribs |
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Sternum |
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Thoracic Spine |
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Alarm Points |
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Skin |
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Abdomen |
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Diaphragm |
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Solar Plexus |
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Right upper Quadrant |
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Mid-Epigastrium |
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Left Upper Quadrant |
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Left |
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Right Upper Quadrant |
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Umbilical Area |
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Supra-pubic Area |
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Inguinal Area |
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Genitals |
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Pelvis |
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Rectum |
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Prostate |
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Hara |
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Alarm Points |
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Waist |
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Skin |
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Extremities |
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Shoulders |
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Arm Alarm Points |
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Hands |
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Fingers |
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Wrists |
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Elbows |
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Forearm |
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Fingernails |
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Arm Neuro Strength & ROM |
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Hips |
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Knees |
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Ankles |
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Foot |
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Toes |
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Toe Nails |
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Leg Alarm Points |
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Leg Neuro Strength & ROM |
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Alarm Points |
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Lung 1 Lung |
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CV-12 Stomach |
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CV-14 Heart |
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CV-17 Pericardium |
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Liv-13 Spleen |
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Liv14 Liver |
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GB-24 Gallbladder |
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GB-25 Kidney |
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Stomach 25 Large Intestine |
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CV-5 Triple Warmer |
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CV-4 Small Intestine |
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CV-3 Bladder |
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TCM Internal Organs
|
Organ |
Qi |
Blood |
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Excess |
Weak |
Rebel |
Prolapse |
Stagna-tion |
Heat |
Cold |
Deficiency |
Stagnation |
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Heart Pericardium Small Intestine |
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Spleen Stomach |
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Lung Large Intestine |
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Kidney Bladder |
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Liver Gallbladder |
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Pericardium Triple Warmer |
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Tender Back Points |
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Vertebra |
Bladder Point |
Organ |
Nervous System |
Left Side |
Right Side |
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T-1 |
11 |
sea of blood |
Hands, thyroid |
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T-2 |
12 |
wind gate |
Heart |
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T-3 |
13 |
lung |
Lungs, bronchi, pleura, chest |
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T-4 |
14 |
pericardium |
Gallbladder, Common Duct |
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T-5 |
15 |
heart |
Liver, solar plexus |
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T-6 |
16 |
governor |
Stomach, Mid-back |
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T-7 |
17 |
diaphragm |
Pancreas, duodenum |
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T-8 |
extra |
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Spleen, low mid back |
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T-9 |
18 |
liver |
Adrenal Glands |
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T-10 |
19 |
gallbladder |
Kidneys |
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T-11 |
20 |
spleen |
Ureters |
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T-12 |
21 |
stomach |
Small Intestine, upper-low back |
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L-1 |
22 |
triple burner |
Iliocecal valve, large intestine |
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L-2 |
23 |
kidney |
Appendix, abdomen, upper leg |
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L-3 |
24 |
sea of qi |
Sex
organs, uterus, bladder knees |
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L-4 |
25 |
large intestine |
Prostate, lower back |
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L-5 |
26 |
gate of origin |
Sciatic, lateral leg and feet |
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Sacrum |
27 28 29 30 |
Small intestine Bladder |
Hip, buttocks, rectum, anus |
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Piriformis |
GB 30 |
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Sciatic nerve |
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GB-20 |
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GB-21 |
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Bl-10 |
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Screening Guidelines for Non-risk, Healthy Adults
|
Evaluation |
Guidelines- Non-risk, Healthy Adults |
Dates
Performed |
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Physical Health Exam |
Periodically |
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Cholesterol Screening |
Every 5 years. Men
beginning at age 35, Women at age 45. |
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Pap Smear (F) |
Every 1-3 years to age 65 |
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Mammogram (F) |
Every 1-2 years, over age
49 |
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Breast exam (F) |
Every 1-2 years |
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PSA (M) |
At clinician's discretion |
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Sigmoidoscopy |
Every 3-5 years after age
19 |
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Glaucoma |
Blacks - ages 20-45 every
3-5 years |
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Vision |
Every 2-5 years after age
40 |
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Vaccinations |
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Vaccine |
Dates Performed |
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Influenza |
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Pneumovax |
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Td |
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Hepatitis B |
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Hepatitis A |
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MMR |
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Varicella |
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Ranges of Personal Discipline Styles |
|
|
Strong willed |
Lazy |
|
Perfectionist |
Sloppy |
|
Self-promoting |
Self-defeating |
|
Orderly |
Haphazard |
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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 |
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Deep vision |
Short-sighted |
|
Clear minded |
Foggy minded |
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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 |
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Date |
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Date |
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Date |
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Date |
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Date |
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Date |
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Date |
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Date |
Problem
List
|
Problem |
Strategy
to Resolution |
Resolved |
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