Health Assessment Form-Male (PDF) - DuPage Neurology & Wellness

Section M-11 Hyper-T Never AlwaysHeart palpitations 0 1 2 3Inward trembling 0 1 2 3Increased pulse, even at rest 0 1 2 3Nervous and emotional 0 1 2 3Insomnia 0 1 2 3Night sweats 0 1 2 3Difficulty gaining weight 0 1 2 3Section M-12 Hypo-P Never AlwaysDiminished sex drive 0 1 2 3Increased ability to eat sugars without symptoms 0 1 2 3Section M-13 Hyper-P Never AlwaysIncreased sex drive 0 1 2 3Tolerance to sugars reduced 0 1 2 3“Splitting” type headaches 0 1 2 3Section M-14 AP Never AlwaysDischarge from breastYes / NoDecrease in libido 0 1 2 3Decrease in spontaneous morning erections 0 1 2 3Decrease in fullness of erections 0 1 2 3Difficulty in maintaining morning erections 0 1 2 3Spells of mental fatigue 0 1 2 3Inability to concentrate 0 1 2 3Episodes of depression 0 1 2 3Muscle soreness 0 1 2 3Decrease in physical stamina 0 1 2 3Unexplained weight gain 0 1 2 3Increase in fat distribution around chest and hips 0 1 2 3Sweating attacks 0 1 2 3More emotional than in the past 0 1 2 3Section M-15 AIDoes Echinacea make your symptoms better/worse? B W ?Does coffee make your symptoms better/worse? B W ?Gums bleed when you brush your teeth 0 1 2 3Bruise easily 0 1 2 3Section NT-1 General Function Never AlwaysIs your memory noticeably declining? 0 1 2 3Are you having a hard time remembering names and phone 0 1 2 3numbers?Is your ability to focus noticeably declining? 0 1 2 3Has it become harder for you to learn things? 0 1 2 3Have a hard time remembering your appointments? 0 1 2 3Is you temperament getting worse in general? 0 1 2 3Are you losing your attention span endurance? 0 1 2 3Find yourself down or sad? 0 1 2 3Fatigue when driving compared to the past? 0 1 2 3Fatigue when reading compared to the past? 0 1 2 3How often do you walk into rooms and forget why? 0 1 2 3How often do you pick up your cell phone and forget why? 0 1 2 3Ever used GABA to fall asleep? Yes NoSection NT-2 Stress Never AlwaysYou are under a high amount of stress 0 1 2 3Feel that you have something that must be done 0 1 2 3Feel you never have time for yourself 0 1 2 3Feel you are not getting enough sleep or rest 0 1 2 3You are getting regular exercise 0 1 2 3Feel as if people don’t care about you 0 1 2 3Feel you are not accomplishing your life’s purpose 0 1 2 3Feel you have no one to share your problems with 0 1 2 3Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being lowest)No stress 1 2 3 4 5 6 7 8 9 10 Extreme stressSection NT-3 S Never AlwaysLosing your pleasure in hobbies and interests 0 1 2 3Feel overwhelmed with ideas to manage 0 1 2 3Have feelings of inner rage (anger) 0 1 2 3Feelings of paranoia 0 1 2 3Feel sad or down for no reason 0 1 2 3Feel like you are not enjoying life 0 1 2 3Feel you lack artistic appreciation 0 1 2 3Feel depressed in overcast weather 0 1 2 3Losing enjoyment for your favorite activities 0 1 2 3Losing enjoyment for your favorite foods 0 1 2 3Losing enjoyment of friendships/relationships 0 1 2 3Difficulty falling into a deep restful sleep 0 1 2 3Have feelings of dependency on others 0 1 2 3Feel an increased susceptibility to pain 0 1 2 3Have feelings of unprovoked anger 0 1 2 3Losing interest in life 0 1 2 3Section NT-4 D Never AlwaysHave feelings of hopelessness 0 1 2 3Have self-destructive thoughts 0 1 2 3Have an inability to handle stress 0 1 2 3Have anger/aggression while under stress 0 1 2 3Feel unrested even after long hours of sleep 0 1 2 3Prefer to isolate yourself from others 0 1 2 3Unexplained lack of concern for family/friends 0 1 2 3Easily distracted from tasks 0 1 2 3Inability to finish tasks 0 1 2 3Feel need to consume caffeine to stay alert 0 1 2 3Feel your libido has decreased 0 1 2 3Lose your temper for minor reasons 0 1 2 3Have feelings of worthlessness 0 1 2 3Section NT-5 G Never AlwaysFeel anxious or panic for no reason 0 1 2 3Feelings of dread or impending doom 0 1 2 3Feel knots in your stomach 0 1 2 3Feelings of being overwhelmed for no reason 0 1 2 3Feelings of guilt about everyday decisions 0 1 2 3Mind feels restless 0 1 2 3Find it difficult to turn your mind off when you want to relax 0 1 2 3Feelings of disorganized attention 0 1 2 3Worry about things that your were not worried about before 0 1 2 3Feelings of inner tension and inner excitability 0 1 2 3Section NT-6 ACH Never AlwaysFeel your visual memory (shapes and images) has decreased 0 1 2 3Feel your verbal memory is decreased 0 1 2 3Memory lapses 0 1 2 3Decrease in creativity 0 1 2 3Decrease in comprehension 0 1 2 3Difficulty calculating numbers 0 1 2 3Difficulty recognizing objects/faces 0 1 2 3Feel like your opinion of yourself has changed 0 1 2 3Excessive urination 0 1 2 3Slower mental response 0 1 2 3Updated 12/13/12 DuPage Neurology & Wellness Center Page 2 of 4386 Pennsylvania Ave #1SE, Glen Ellyn, IL 60137p (630) 445-1218 f (630) 206-2853

Health HabitsTobacco:Cigarettes: #/day _______________Cigars: #/day __________________Alcohol:Wine: # glasses d / w ____________Liquor: # ounces d / w ___________Beer: # glasses d / w ____________Caffeine:Coffee: # 6 oz cups/d ____________Tea: # 6 oz cups/d ______________Soda: # cans/d _________________Other sources _________________water: # glasses/d ___________Skin creams _______________Exercise5-7 days per week3-4 days per week1-2 days per week45 min or more duration/workout30-45 min duration/workoutLess than 30 min/workoutWalk # days/week ___________Run/other aerobic days/week __Weight lift # days/week _______Stretch # days/week _________Other ____________________Nutrition/DietMixed food (animal/veg sources)VegetarianVeganSalt restrictionFat restrictionStarch/carbohydrate restrictionTotal calorie restrictionSpecific food restrictions:Dairy Wheat/glutenEggs Soy CornOther _____________________The three worst foods you eat duringthe average week?_______________________________________________________________________________________The three healthiest foods you eatduring the average week?_______________________________________________________________________________________Favorite food __________________Food FrequencyNumber servings per day:Fruits (citrus, melons, etc) ________Dark green, yellow/orange veg ____Grains (unprocessed) ___________Beans, peas, legumes ___________Dairy _______ Eggs ____________Meat, poultry, fish ______________Eating HabitsSkip meals ________________# meals consumed/day __________Graze (small frequent meals)Generally eat on the runEat constantly, hungry or notDo you consider yourself:Underweight OverweightJust right Weight today ______Bowel movements/day ___________Current SupplementsMultivitamin/mineralVitamin CVitamin EEPA/DHACalciumMagnesiumZincProbioticsDigestive EnzymesCoQ10HerbsHomeopathyProtein Shakes/liquid mealsOthers _________________________________________________Medication HistoryCircle if currently taking and indicatedurationAntacidsAntibioticsAntifungalsAntihistaminesAntidepressantsInsulin Support AgentsNSAIDS/Anti-inflammatoryagentsAnxiety MedicationsBlood pressure lowering agentsCholesterol lowering agentsOral ContraceptivesHormonesLaxativesDiureticsCortisone (cream/injection/pill)Other medications, including overthe-countermeds. Indicate reasonfor taking and length of time on eachmedication.______________________________________________________________________________________________________________________________________________________________________________Review of SystemsEyes/VisionWear glasses/contactsRecent change in visionCataractsEye painGlaucomaMacular DegenerationCardiovascularChest pain/discomfortLeg pain/acheHeaviness in legsPain in shoulder/jawHeart murmurPalpitationsRapid pulseHigh blood pressureLow blood pressureVaricose veinsSwelling in feet/anklesDifficulty breathing when lyingdownWake at night with shortness ofbreathRespirationCoughShortness of breathWheezingExcessive sputum productionEmphysemaSkinUnusual pattern of hair growthChanges in skin colorChanges in wart/moleHivesSore that won’t healItchingRashSkin lesions/ulcersMedical Historyyes / Part II Medication HistoryPlease indicate if you have, or haveever had, any of the following:Allergies ___________________ArthritisAlzheimer’s diseaseBronchitisCancerChronic fatigue syndromeCarpal tunnel syndromeCholesterol/triglycerides elevatedColitisEating disorderEpilepsyFibromyalgiaFood intolerancesGastroesophageal reflux diseaseGoutHeart diseaseKidney disease/stonesLearning disabilityLiver diseaseMental illnessNeurological problemsObesityOsteoarthritisPneumoniaSexually transmitted diseaseSkin cancerStrokeThrombophlebitisTuberculosisType II DiabetesUrinary tract infectionsSection AIAlopecia AreataAsthmaCeliac DiseaseCrohn’s Disease*DermatomyositisEndometriosisGrave’s DiseaseHashimoto’s diseaseInterstitial CystitisLupus Erythematosus (SLE)Multiple Sclerosis*Myasthenia Gravis*NarcolepsyPernicious AnemiaPsoriasis*Rheumatoid ArthritisSchizophrenia*SclerodermaSjogren’s Syndrome*Temporal ArteritisType I DiabetesUlcerative ColitisVasculitisVitiligoWegener’s GranulomatosisSection CAddison’s DiseaseAnemiaAtaxia/Nerve Diease/NeuropathyAttention Deficit DisorderAutismBacterial Overgrowth (Intestinal)Bloating, gas, or stomachcrampingCandida AlbicansCanker SoresCasein/Lactose IntoleranceChronic Fatigue SyndromeCognitive ImpairmentConstipationDiarrhea or runny stoolsDepressionDermatitis HerpetiformisDyspepsia/Acid RefluxEczemaEpilepsyFibromyaligiaFlatulence (Gas)Gallbladder DiseaseGastrointestinal BleedingGrowth Hormone DeficiencyHeart FailureJoint PainInfertility/MiscarriageInflammatory Bowel DiseaseIntestinal PermeabilityIrritable Bowel SyndromeKidney DiseaseLactose IntoleranceLiver DiseaseMalnutritionMigraines or headachesNon-Hodgkin’s LymphomaNumbness/tingling in extremitiesObesityOsteopenia/-porosisPancreatic DisordersPeripheral NeuropathyPsychiatric disordersSarcoidosisSepsisSmall Intestinal CancerThrombocytopenic PurpuraThyroid disordersTuberculosisFamily history of the aboveconditions (* item if it was cause ofdeath)______________________________________________________________________________________________________________________________________________________________________________Traveled outside the U.S. in past5 years ___________________Health Hx 1.2 Last Updated 11/08/10 DuPage Nuerology & Wellness Center Page 3 of 4578A Duane St., Glen Ellyn, IL 60137(630) 445-1218

I Would Like to:Energy/VitalityFeel more vitalHave more energyHave more enduranceBe less tired after lunchSleep betterBe free of painGet less colds and fluGet rid of allergiesNot be dependent upon OTC meds like aspirin, ibuprofen, anti-histamines, sleep aids, etc.Stop using laxatives and stool softenersImprove sex driveBody CompositionLoose WeightBurn more body fatBe strongerHave better muscle toneBe more flexibleStress, Mental, EmotionalLearn how to reduce stressThink more clearly and be more focusedImprove memoryBe less depressedBe less moodyBe less indecisiveFeel more motivatedLife EnrichmentReduce my risk of degenerative diseaseSlow down accelerated agingMaintain a healthier life longerChange from a “treating illness” orientation to creating a wellness lifestyle__________________________________________Patient Signature/dateHealth Hx 1.2 Last Updated 11/08/10 DuPage Nuerology & Wellness Center Page 4 of 4578A Duane St., Glen Ellyn, IL 60137(630) 445-1218