DOW EXECUTIVE CHECKUP

PATIENT HISTORY FORM

Date -______________
Personal History
Name: ________________________________________ Date of Birth____/____/______(mm/dd/yyyy) Age____________
Occupation ______________________ Birthplace___________________________( City & Country )
Height__________________inches Weight____________________( lbs or Kg )
Preferred Language for consultation 1st____________________2nd____________________( English, Hindi, Urdu, Punjabi )
Patient Ph#_________________________________ cell # _______________________________________________

ALLERGIES: Like Food, Pollens, Odors, Medicines, Pets etc

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MAIN PROBLEMS FOR CONSULTATION: (if possible, rank in terms of importance to you)

1. _______________________________________________________________________________________________________

2. _______________________________________________________________________________________________________

3. _______________________________________________________________________________________________________

4. _______________________________________________________________________________________________________

5. _______________________________________________________________________________________________________

Additional problems or concerns you would like to be addressed:

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_____________________*Note: we may not be able to address every problem during the course of one treatment.

Current Medications Dose Times / Day

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Current Herbs / Vitamins/ Homeopathy/ Supplements Dose Times / Day
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PAST MEDICAL, SURGICAL & TRAUMA HISTORY Patient Name:

List prior illness, injury, hospitalization, surgery, and/or trauma:
Reason: Date/Month and Year
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PERSONAL AND FAMILY HISTORY

Check those that apply and tick your problem if any..
Yourself Mother Father Grandparents Sister/ Brother Spouse Children
Allergies
Alzheimers
Anemia
Arthritis
Asthma
Birth Defects
Bleeding Disorder
Breast Cancer
Cancer
Depression
Diabetes
Emphysema
Epilepsy
Glaucoma
Heart Disease
High Blood Pressure
IBS
Kidney Disease
Liver Disease
Mental Illness
Migraine Headaches
Pneumonia
Stroke
Tuberculosis
Ulcers
Other
SOCIAL HISTORY (check those that apply): Patient Name:
Marital status: Education level completed: Memories of your childhood Do You Find Your Life
single high school Mostly happy Generally Unsatisfactory
married college Mostly painful Too Demanding
divorced professional school Normal Boring
Widowed other: dont recall Satisfactory
Living arrangement:
alone family roommate significant other
children (list sex/ages):_________________________________________
Major stresses in last 2 years Money Job Marriage Home Life Children
other stress___________________________________________________________________________________________

Pertinent travel history:(out of Country areas)

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LIFESTYLE / SELF-CARE ISSUES

Do you smoke cigarettes? YES NO If yes, how many? #_____yrs. ______________ packs per day
Did you ever smoke? YES NO If yes, when did you quit? ______________
Do you drink caffeine beverages? YES NO If yes, which? ________________________________________
Do you use recreational drugs? YES NO If yes, which? _________________________________________
Do you manage stress well? YES NO NOT SURE NEED HELP
Do you exercise regularly? YES NO If no, why? _________________________________________
Do you enjoy your job? YES NO If no, why? _________________________________________
Do you sleep soundly? YES NO If no, why? _________________________________________
Are you satisfied with your social life? YES NO If no, why? _________________________________________
Are you satisfied with your spiritual life? YES NO If no, why? _________________________________________
Is your diet healthy enough? YES NO NOT SURE NEED HELP

Typical
breakfast__________________________________________________________________________________________________
_

Typical lunch
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Typical
dinner_______________________________________________________________________________________________
Typical
snacks_______________________________________________________________________________________________

Devices
Do You Use:
___Eyeglasses ______Contact Lens ______Hearing Aid ______Dentures

___Brace (Neck, Back) ______ Pacemaker ______ IUD, Diaphragm ______Artificial Limbs

REVIEW OF SYSTEMS Patient Name:

Check any symptoms that currently apply to you:
Constitutional Mouth, Throat Muscles, Bones & Joints Digestion & Intestines
___ poor appetite ___ tongue discoloration ____neck pain ____indigestion
___ fevers ___ bad breath ____back pain ____belching/ flatulence
___ chills ___ teeth problems ____muscle pain ____difficulty swallowing
___ food craving ___ grinding teeth ____ painful joints: R__L__ ____heartburn/ ulcer
___ weight loss ___ tonsillitis/ adenoids ____shoulder ____elbow ____nausea
___ weight gain ___ facial pain ____hip____ knee ___ankle ____ liver trouble
___ fatigue ___ sore throat ____wrist _____fingers ____ vomiting
Eyes ___ ulceration tongue ____joint swelling ____ diarrhea
___ eye pain ___ gum bleeding ____muscle weakness ____ cramping bowels
___ blurred vision Heart & Circulation ____muscle cramps ____ food allergies
___ poor vision___day ____chest pain Skin, Hair ____constipation
___ poor vision___night ____ lightheadedness ____ psoriasis ____ abdominal pain
___ wear corrective lenses ___ palpitations ____ warts ____rectal pain/ itching
___ near____far sighted ____ cold hands/feet ____ freckles ____ hemorrhoids/ piles
___ other ____ fainting ____ itching, hives ____ blood in stool
Ears, Nose ____ swelling feet ____ hair loss Urine, Kidney, Bladder
___ ringing ears ____ blood clots ____ dry skin, eczema ____painful urination
___ nosebleed/polyp ____ varicose veins Nerves, Movement, Brain ____wake up to urinate
___postnasal drip Breathing & Lungs ____ seizures ____kidney stones
___sinus problems _____shortness of breath _____nerve pain ____ loss of control
___trouble with taste/smell _____wheezing or asthma _____poor balance ____ frequent urination
___poor hearing _____repeated colds/ flu _____poor coordination ____ sudden urging
___earaches/ infections _____ cough dry/ irritating _____tremors or shaking ____ blood/pus urine
___sneezing/ discharges _____headaches ____urine infection UTI

Immune System Sexual Organs Women Reproductive

____too many infections ____ sores on genitals _____ pelvic pain ____age period started
____allergies to food ____ lumps or swelling _____ vaginal discharge ____ # of pregnancies
____allergies to environment ____ erection problems _____ painful periods ____# abortions
___ other concerns ____ premature ejaculation _____premenstrual syndrome ____# miscarriages
Blood System ____pain with sex _____ hot flashes ____# live births
____lymph gland swelling ____infertility _____ itching or soreness ___children currently living
____anemia ____repeated infections _____irregular menses ___age menopause ___
____easy bruising ____aversion to sex _____leucorrhoea ___past infertility
Mind Symptoms Thermal State
____memory ___hot
____temper/anger ___chilly
____emotional
____sleep

Additional Symptoms --
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IF NOT NOTED IT IS EITHER NEGATIVE, NON-CONTRIBUTORY, AND/ OR NON-PERTINENT.

HEALTH SCREENING HISTORY Patient Name:

List the date of your most recent test or exam.
Mammogram _________ Pap Smear__________ Self Breast Exam ___________Breast Exam by Doctor____________
Blood test for Cholesterol _________ Blood Sugar ________Other Blood tests__________________________________
Immunizations: Tetanus_______________Hepatitis______________MMR____________________Flu Shot_____________________
Test for Blood in stool_______ Rectal Exam ______________Feeling the Prostate_________ Scope Lower Bowel_______________
Self Exam Testicle ___________Testicle Exam by Professional____________

Anatomy\Procedure X-ray MRI CT Scan Ultrasound Bone Scan EKG EEG

Back
Brain
Chest
Colon
Extremities (Arm/ Leg)
Gallbladder
Kidney
Neck
Pelvis
Stomach
Other

>>Copies of reports should be sent with the patient form

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Date Patient/ Guardian signature that filled out the history

Address; _____________________________________ Phone Home -- _______________________

 Cell -- __________________________
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Email -- __________________________

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