|
GENERAL INFORMATION Today's date ___________ Name _______________________________________________ Age _____ Sex (M,F) ______ Place of birth ____________________________ Birth date ____________ Marital status ________________________ Number of children _____ Living situation (alone, family, friends) ____________________________ Occupation _________________________________________ Address _____________________________________________________________ City _______________________________________ State/Zip/Country __________________ E-mail address _____________________________________ Fax_____________________ Phone (home) _____________________ Phone (work/cell) ______________________ OPTIONAL (sometimes it can help explain your health problem) Religion _________________________ Race ______________ COMPREHENSIVE HEALTH HISTORY Please describe your current symptoms and problem areas. If you have received a diagnosis, please include the diagnosis and date received. Personal Medical History Date Diagnosed Treatment Taken High Blood Pressure __Yes __No ____________ ______________ Heart Disease __Yes __No ____________ ______________ Stroke/Thrombosis __Yes __No ____________ ______________ Diabetes __Yes __No ____________ ______________ Arthritis __Yes __No ____________ ______________ Liver/Gall Bladder Disease__Yes __No ____________ ______________ Kidney Disease __Yes __No ____________ ______________ Seizure Disorder __Yes __No ____________ ______________ Lung Disease __Yes __No ____________ ______________ Asthma __Yes __No ____________ ______________ Emphysema __Yes __No ____________ ______________ Other: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Cancer: Type:_________________ ____________ ______________ Type:_________________ ____________ ______________ Type:_________________ ____________ ______________ Have you had any chemotherapy? __Yes __No If yes, how many treatments? _____________________________________ For how long did you receive radiation? _____________________________ Was the radiation __successful __not successful __no effect Please list all surgeries (i.e., include cosmetic, implants, biopsies): Name of surgical procedure: Year: 1. ________________________________________ ______________ 2. ________________________________________ ______________ 3. ________________________________________ ______________ 4. ________________________________________ ______________ 5. ________________________________________ ______________ 6. ________________________________________ ______________ 7. ________________________________________ ______________ 8. ________________________________________ ______________ 9. ________________________________________ ______________ 10.________________________________________ ______________ Any tattoos or piercings? __Yes __No. If yes, when and where? __________ _____________________________________________________________ To your knowledge, are you HIV positive? __Yes __No To your knowledge, do you have AIDS? __Yes __No Have you had any blood transfusions? __Yes __No Blood type, if known: ____ If yes, when? ___________________________________________________ What is your current stress level (5 high)? __1 __2 __3 __4 __5 Past Occupations: ______________________________________________ _____________________________________________________________ Have you been exposed to any of the following? Agricultural chemicals __Yes __No Industrial/Workplace chemicals __Yes __No Cigarette smoking __Yes __No If yes, how much? _______________ For how long? _____________ Date of last cigarette smoked? ________________________________ Second hand smoke/how much/how long? ______________________ Alcohol use? __Yes __No How much? _______________ Recreational drugs? __Yes __No How much? _______________ How long? ___________________________ “Street drugs” __Yes __No If yes, which ones? __________ Dental History Do you have silver mercury fillings? __Yes __No If yes, how many? _________ Do you have root canals? __Yes __No If yes, how many? ___________ Have you been tested for having metal toxicity? Food Issues / Sensitivities Do you have any food allergies? __Yes __No if yes, please list ________________________________________________ Do any foods give you significant gas, pain, or bloating? __Yes __No If yes, please list ________________________________________________ Please describe your diet (e.g., fresh organic vegetables and fruit, restaurants 3 times per week): _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Stomach Disorders or General Digestion Problems Acid Indigestion __No __Yes, in the past __Yes, currently Acid Reflux __No __Yes, in the past __Yes, currently Bloating/Flatulence __No __Yes, in the past __Yes, currently Colitis __No __Yes, in the past __Yes, currently Constipation __No __Yes, in the past __Yes, currently Diarrhea __No __Yes, in the past __Yes, currently Diverticulitis __No __Yes, in the past __Yes, currently Hiatal Hernia __No __Yes, in the past __Yes, currently Irritable Bowel Syndrome __No __Yes, in the past __Yes, currently Ulcers __No __Yes, in the past __Yes, currently Current Medications Please list, including Dosage When you started taking it 1. ________________________________ _____________________ 2. ________________________________ _____________________ 3. ________________________________ _____________________ 4. ________________________________ _____________________ 5. ________________________________ _____________________ 6. ________________________________ _____________________ 7. ________________________________ _____________________ 8. ________________________________ _____________________ 9. ________________________________ _____________________ 10. ________________________________ _____________________ Note: Please do not discontinue any medications until advised by your Gerson practitioner or private medical doctor. Please list any supplements, vitamins, or herbs you are taking, including : Dosage When you started taking it 1. ________________________________ _____________________ 2. ________________________________ _____________________ 3. ________________________________ _____________________ 4. ________________________________ _____________________ 5. ________________________________ _____________________ 6. ________________________________ _____________________ 7. ________________________________ _____________________ 8. ________________________________ _____________________ 9. ________________________________ _____________________ 10. ________________________________ _____________________ Have you contracted any of the following disease/infections? Sexually Transmitted Diseases Syphilis __Yes __No Gonorrhea __Yes __No Genital Herpes __Yes __No Genital Warts __Yes __No Chlamydia trachomatis __Yes __No Miscellaneous: Candida albicans __Yes __No Trichomonas vaginalis __Yes __No Other, please list: _________________________________________ _____________________________________________________________ Bacterial/viral infections: Herpes simplex __Yes __No Tuberculosis __Yes __No Malaria __Yes __No Meningitis Viral __Yes __No Bacterial __Yes __No Encephalitis __Yes __No Streptococcal __Yes __No Staphylococcal __Yes __No Septicemia __Yes __No Brucellosis __Yes __No Candidiasis __Yes __No Listeria __Yes __No Salmonella __Yes __No Camphylobacter __Yes __No Heliobacter __Yes __No Dysentry __Yes __No Hepatitis A __Yes __No If yes, when infected? __________ B __Yes __No If yes, when infected? __________ C __Yes __No If yes, when infected? __________ Epstein Barr __Yes __No Cytomegalovirus __Yes __No Other pertinent history or information: __________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Females Only: Age at onset of menstruation? _________ How many pregnancies? ________ Miscarriages _________ Abortions _______ Number of children? ____________ Alive ________ Deceased ________ How many Cesarean sections? _________ Age at onset of menopause? ___________ Have you taken oral contraceptive pills? __Yes __No If yes, for how long? _______ Have you taken Hormone Replacement Therapy (HRT)? __Yes __No If yes, for how long? _______________________________________________ Have you experienced any other following (please check)? absence of periods __ cervical dysplasia __ endometriosis __ hemorrhage __ infection in reproductive organs __ infertility __ yeast infections __ ovarian cysts __ premature birth __ still birth __ diabetes during pregnancy __ pelvic inflammatory disease __ tubal pregnancy __ toxemia __ irregular cycle __ placenta previa __ uterine fibroids __ Family History Mother: __Alive __Deceased Father: __Alive __Deceased Sisters: Number Alive ___ Number Deceased ___ Brothers: Number Alive ___ Number Deceased ___ Please insert the names of the family members wherever it applies below. Include mother, father, brothers, sisters, aunts, uncles, grandparents and your children. High Blood Pressure __Yes __No ____________________________ Heart Disease __Yes __No ____________________________ Stroke-Thrombosis __Yes __No ____________________________ Diabetes __Yes __No ____________________________ Arthritis __Yes __No ____________________________ Liver/Gall Bladder Disease__Yes __No ____________________________ Lung Disease __Yes __No ____________________________ Asthma __Yes __No ____________________________ Emphysema __Yes __No ____________________________ Kidney Disease __Yes __No ___________________________ Seizure Disorder __Yes __No ____________________________ Auto-immune disease __Yes __No ____________________________ Rheumatoid Arthritis__Yes __No ____________________________ SLE (Lupus) __Yes __No ____________________________ Celiac __Yes __No ____________________________ Chrons __Yes __No ____________________________ Hyper-thyroidism __Yes __No ____________________________ Hypo-thyroidism __Yes __No ____________________________ Multiple Sclerosis __Yes __No ____________________________ Mental Disease/Depression__Yes __No ___________________________ Cancer Type___________________Relative_______________ Type___________________Relative_______________ Type___________________Relative_______________ Type___________________Relative_______________ Other: ______________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Social History Do you have family/friends for a support system? __Yes __No Have you recently experienced any losses (i.e., family / friend / job / pet / divorce / financial / mobility / independence)? __Yes __No If yes, please explain: _____________________________________________ _______________________________________________________________ Do you have a spiritual or religious practice, belief system or faith community? __Yes __No ___________________________________________________________ Optional Exercise As an optional self-help exercise, please take a few moments to draw a picture of: 1. How you see yourself in association with your family (stick figures are fine). 2. If you have cancer, please draw a picture of how you see or feel the cancer in your body. Note: You can alternatively download a wordfile with the same content - like this: right-click here, and choose "save (link) target as". |
|
HAWAII GERSON THERAPY RETREAT 17-502 Ipuaiwaha, Keaau, HI 96748 Tel/Fax: 808 982 8202 Email: doctor@gersonhawaii.us |
|
|