NEW PATIENT QUESTIONNAIRE...to deal with specific health concerns. State Postcode/Zip Country Full...
Transcript of NEW PATIENT QUESTIONNAIRE...to deal with specific health concerns. State Postcode/Zip Country Full...
NEW PATIENT QUESTIONNAIRE
Please take the time to accurately complete this form.This will enable our time together to be more efficient and targeted.
Date
By completing this form, you understand, acknowledge and agree that:
• all information on this form and during any subsequent consultations is true and correct to the best of your knowledge.
• You acknowledge that failure to provide information about your current or past health may compromise the quality of health care and the treatment provided.
• You agree to inform your practitioner (Kate Smyth) of any changes to your current• medical/health condition, including any new medications (pharmaceutical, herbs, vitamins or
other supplements), pregnancy status (if female), new injuries or diagnosed/undiagnosed med-ical conditions.
• All personal details and records captured on this form and shared during consultations will be stored safely. This information will be kept confidential and will not be released to any other person without written consent, unless required by law.
• A copy of the Athlete Sanctuary’s Privacy Policy and Terms & conditions are available on the website www.athletesanctuary.com.au
• The Athlete Sanctuary is unable to give a professional opinion regarding health via email or telephone. General enquiries may be answered by telephone, but an appointment is necessary to deal with specific health concerns.
Postcode/ZipStateCountry
Full NameDate of Birth AgeStreet Address Town/Suburb
Preffered Contact Number
Preferred E-mail (where correspondence will be sent)Occupation
Emergency Contact
In Relationship to Me
General Physician’s Name Phone
Phone
NameSpecialist ( Sports Medicine G.P., Oncologist, Endocrinologist, Etc.)
Phone
What are you coming to see the Athlete Sanctuary for?
Is there anything specific that you would like us to provide?
E.g. Help with managing my digestive system
E.g. Suggestions on diet management of my condition
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NEW PATIENT QUESTIONNAIRE
MEDICATIONS:
THE ATHLETE SANCTUARY | NEW PATIENT QUESTIONNAIRE 02
Current pharmaceutical medications including contraception and over the counter medications. Please include dosage, brand and reason for taking:
NAME DOSAGE PER DAY REASON
Current nutritional supplements, herbs, homeopathic medicines orflower essence. Please include dosage, brand and reason for taking:
NAME DOSAGE PER DAY REASON
When was your last course of antibiotics?
What was the antibiotics for?
YES
NO
Have you had any blood tests or other diagnostictests completed in the past 6 months? (please bring these along to your consultat ion)
NEW PATIENT QUESTIONNAIRE
MEDICAL HISTORY:
FAMILY HISTORY:
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EVENT / ILLNESS AGE
If so please list
Known allergies or intolerances?
YES
NO
I have more to add to my list of event/illnesses
Main Life Events / Illnesses
Do you have any diagnosed medical conditions
For example:
• Childhood asthma age 6-18 years• Recurrent respiratory infections age 12-15 years• Divorced age 30 years• Stress fracture left shin 35 years• Loss of loved on 55 years
Has anyone in your family (mother, father, aunty, uncle, grandparents, siblings or children) been diagnosed with a major illness? Such as cancer, heart disease, thyroid issues, mental health issue, alzheimer’s disease, arthritis, high blood pressure, high cholesterol or other)
Please list
YES NO
YES NO
NEW PATIENT QUESTIONNAIRE
DIGESTION / GASTROINTESTINAL SYSTEM
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Reflux
Bloating/Fullness
Discomfort/Pain in the abdominal region
Nausea
Vomiting
Flatulence
My stomach feels unsettled when I am stressed
I am a gut thinker
Constipation
Diarrhea
Fluctuating between diarrhea and constipation
Anorexia, bulimia or other Obsessions with some food
Burning sensation
Gnawing feeling between meals
Mucous in stool
Blood in stool
Recent change in appetite
Low appetite in the morning
Anal itchiness
Pale and/or floating stool
Pain on voiding stool
YES NO
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
How often do you move your bowels each day?
Overseas travel in past 12 months and to what destination?
Food poisoning in the past 3 months YES NO
NEW PATIENT QUESTIONNAIRE
NERVOUS SYSTEM
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Anxiety
Depression
Mood changes
Headaches
Migraines
Excessive sweating
Dizziness/Light-headedness
Numbness/tingling
Seizures
I need to exercise in the morning to feel energized
I feel “flat“ on a rest day from exercise
I suffer from post-traumatic stress disorder
I have lost a loved one in the past 6 months
Loss of memory/concentration
Have you experienced long periods of stress levels?
Current stress level (10 very stressed, 1 not stressed at all)
Quality of sleep currently (10 excellent, 1 poor)
Difficulty getting up in the morning (don’t really wake up until 10am)
Changes in sleep quality or pattern
Number of hours of sleep per night (average)
Broken sleep?
Why?
Wake feeling rested?
Current energy level out of 10 (10 bouncing out of skin, 1 exteme fatigue)
I usually feel my best after 6PM
History of high alcohol intake (> 6 standard drinks per night)
History of current and/or substance use
YES NO
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
NEW PATIENT QUESTIONNAIRE
EAR, NOSE, THROAT AND RESPIRATORY
IMMUNE
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Ringing in the ears
Seasonal allergies/hayfever
Sinus pain/congestion
Coughing/wheezing
Shortness of breath
Ear aches
Blocked nose/sinuses
Gingivitis
Gums bleed easily
Oral thrush
Itchy eyes
Phlegm
Asthma
Amalgam fillings
Recurrent mouth ulcers and/or gum infections
Change in ability to taste
Raised Glands
Recurrent chest infections
Thrush
Bacterial Vaginosis
Cold sores
Urinary Tract Infections
I have environmental/chemical or mold sensitivities
I get cougs/colds
Other immune issues:
YES NO
YES NO
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
NEW PATIENT QUESTIONNAIRE
SKIN / HAIR / NAILS
CIRCULATION / CARDIOVASCUVVLAR / RESPIRATORY SYSTEM
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Acne
Eczema
Psoriasis
Rashes
Itching skin
Skin redness
Darkened skin around armpit or
skin creases in other parts of body
Loss of pigmentation in skin
Slow wound healing/ulcers
Excessive skin dryness
Brittle/dry hair
Noticeable Hair loss
Brittle nails
Bruise easily
Any yellowing of skin or eyes?
History of anemia or low iron
Hemmorroids
Varicose veins
High blood pressure
High cholesterol
Heart palpitations or racing heart
Wheeze
My ankles or feet are sometimes swollen
YES NO
YES NO
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
NEW PATIENT QUESTIONNAIRE
MUSCULOSKELETAL
GENITOURINARY SYSTEM
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Chest pain
Shortness of breath
Cold hands/feet
Reduced tolerance to exercise
Severe fatigue or dizziness with exercise
Joint pain
Muscle cramps
Back pain
Arthritis
Muscle pain
Brokern bones/stress fractures
Eyebrow twitching
Major injuries
Other musculoskeletal issues?
History of urinary tract infections
Painful urination
Increased frequency
Decreased output
Blood in urine
Kidney stones
YES NO
YES NO
YES NO
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
NEW PATIENT QUESTIONNAIRE
ENDOCRINE SYSTEM
FEMALES ONLY
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Sugar cravings Time:
Severe fatigue Time:
Decline in visions (not age related)
Energy decline after meals
Weight gain in past 12 months Gain in kg:
I have gained weight around my middle
Weight loss in the past 12 months Loss in kg:
I get “angry“ when I haven’t eaten for a while
I feel better after fasting
Currently pregnant
How many weeks gestation:
History of miscarriage/pregnancy loss
How many weeks gestation:
Age of first period
Current or previous se of the contraception pill
IUD
Implants
Irregular menstrual cycles
Spotting between periods
Pain mid cycle
PMS
Breast tenderness
Breast lumps
Heavy periods
YES NO
YES NO
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
NEW PATIENT QUESTIONNAIRE
MALES ONLY
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Painful periods
Lower back pain during periods
Infertility of unknown cause
History of any STDs
Post menopause
Low libido
Vaginal dryness
Hot flushes or night sweats
Hair growth or darkening of facial hair or on other parts of body
Date of last pap smear:
Date of last breast examination:
Low libido
Inability to obtain/maintain morning erection
General erectile dysfunction
Prostate issues
History of any STDs
Date of last prostate examination:
YES NO
YES NO
Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?
NEW PATIENT QUESTIONNAIRE
GENERAL INFORMATION
DIETARY ANALYSIS
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I am concerned about my current weight
Do you follow a specific diet?
Do you have any food allergies?
Do you crave sugary foods?
Do you crave salt?
Do you crave any other foods?
Do you crave dirt or ice?
Do you feel like you have enough cookingskills and knowledge?
How many takeaway meals do you have each week?
Do you cook your food at homeand how often?
Do you skip meals?
Inbody or Dexa scan completed in last 3 months?
If you answered YES, please bring copy of the test results on your initial appointment
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
why?
Current Height (cm) Current Weight (kgs)
If you skip meals,please state whichones:
If so which ones
Please list:
Details:
NEW PATIENT QUESTIONNAIRE
24-HOUR FOOD RECALL
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(Please record what you have eaten for the past 24 hours and provide as much detail as possible including brand and amount of food item). E.g. Breakfast 1 cup of quick oats, ½ cup full cream A2 cow’s milk, 1 medium banana and 1 cup black instant coffee
Pre training AM (If applicable) :
Breakfast :
Snack :
Snack :
Dinner :
Desssert :
Total fluids per day (including coffee/ tea, water, alcohol, soft drinks, energy drinks, sports drinks etc: E.g. 6 cups water, 3 beers and 4 cups of coffee) :
Lunch :
NEW PATIENT QUESTIONNAIRE
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Do you consume the following at least once per day or on a regular basis?
How many hours on average per week do you exercise?
At what level do you compete (recreation/club, state, national, international) ?
How many high intensity sessions do you complete per week?
If you are a retired athlete, how many years ago did you retire?
Name of Coaches Phone / email
How many training sessions do you complete thatare over 90 minutes in duration per week?
What form of exercise do you do?
Alcohol
Smoke cigarettes or marijuana
Take recreational drugs
Coffee, tea, coke or energy drinks
Sports drinks
Protein bars or premade protein drinks
EXERCISE AND LIFESTYLE
ATHLETES ONLY (please complete if applicable)
Do you enjoy exercise?
Are you a competing athlete?
Do you have a coach?
How many KMs do you cover per week?
YES NO
YES NO
YES NO
Running Cycling Rowing
NEW PATIENT QUESTIONNAIRE
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ATHLETES ONLY
CHILDREN’S HEALTH
(continuation)
(please complete only if the appointment is for a person under 18 years of age)
Do you travel regularly in your chosen sport?
Is the child breastfed?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
vaginal birth/normal C-section
When was your last major event?
When is your next major event?
When was your last rest period of more than a week?
When were solid foods introduced?
Has your child taken any antibiotics and how many courses?
Any behavioral changes or challenges?
Does your child have any learning difficulties?
Is your child a fussy eater?
Does your child have any sleeping difficulties?
Did your child have any complications during birth?
Did your child have any complications during pregnancy?
If Yes, what were the complications?
If Yes, what were the complications?
If Yes, how long were they breastfed for?
How was your child born?
Event
Event