BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.

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BREAKTHROUGH MEDICINE

SHAIDA SINA, NMD

FEMALE HEALTH HISTORY INTAKE

Last name: First: Middle:

Age: Gender: Marital Status: Date of Birth:

Reason for visit:

Last Medical Visit (date & with whom)

Please Check box if appropriate and note when it was performed.

☐ Thermal or Mammogram: ☐ Colonoscopy or Endoscopy:

☐ Bone Density: ☐ MRI/Cat Scan/Ultrasound/X-ray:

☐ General Blood Work: ☐ Dental Exam:

☐ Hormone Screen: ☐ Eye Exam:

Allergies Reactions (Medicine and Substance):

Please list: Dosage and Frequency of how you are taking Medications and Supplements

Medications (over the counter and prescribed) Supplements (vitamins, amino, herbs….)

Patient Visit Location: Core Chiropractic 2530 W. SR 89A Sedona, AZ 86336

Front Office and Natural Pharmacy: Breakthrough Medicine 10990 Cornville Road, Suite “E”, Cornville, AZ 86325

Phone: 928.649.0269

Fax: 866.644.6363

office@breakthroughmed.com

PRACTICE LOCATION:2530 W. ST. RT. 89A, Suite B1Sedona, AZ 86336

VIRTUAL OFFICE:PO BOX 208Cornville, AZ 86325

Ph: 928-649-0269Fax: 866-644-6363

Email: office@breakthroughmed.comwww.breakthrough-medicine.com

BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.

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Family History: “F”= Father, “M”=Mother, “S”= Siblings, “GP”= Grandparents, “C”=Children

Allergy: Cholesterol: Brain Issues: Prostate Issues:

Anemia: Digestive Issues: Mental Illness: Thyroid Issues:

Asthma: Diabetes: Heart Attack: Lung Issues:

Blood Pressure: Female Issues: Stroke: Autoimmune:

Cancer: Bone Loss: Eye Issues: Adrenal:

List all Surgeries & Hospitalizations, including date occurred:

Please note “D”= Disease, “I”= Immunized, “N”= Neither (also list most recent booster year)

Small Pox: Rubella: Chicken Pox

Measles: Tetanus: Pertussis (whooping cough):

Mumps: Diphtheria: Haemophilus (HIB):

Hepatitis A: Hepatitis B: Polio:

Pneumococcal: Meningococcal: Influenza:

Rotavirus: RSV: Human Papillomavirus:

Please List All Reactions to Vaccinations:

List “Y”= Yes, “N”= No, “P”= Past regarding use of the following, if “yes”, note amount and how often:

Antacids: Steroids: Antibiotics:

Analgesics: Laxatives: Enema:

Coffee: Alcohol: Soda:

Candy/Cookies: Tobacco: Recreational Drugs:

Present Height: Present Weight: Weight one year ago?

Max. weight? When? Min. weight? When? Ideal Weight:

Do you have good energy throughout the day? Explain:

:

BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.

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Do you experience restful sleep? If you answered “No”, please explain:

List last 10 years of type of work you have done: Are you chemically sensitive to odors? If “Yes”, explain:

What are your hobbies?

Do you use pesticides, herbicides, or other chemicals around your home?

Exercise Routine (type and how often:

Past Medical History: Please Check Box

☐Arthritis ☐Emphysema ☐Cancer ☐Anxiety ☐Structural Injury ☐Kidney Disease

☐Allergies ☐Low Blood Pres. ☐Celiac ☐Depression ☐Hepatitis ☐Gallbladder

Disease

☐Asthma ☐High Blood Pres. ☐Cohn’s Disease ☐Diabetes ☐HIV / AIDS ☐Migraines

☐Alcoholism ☐Diverticulitis ☐GERD (heartburn) ☐Bipolar Disorder ☐Sinusitis ☐Thyroid Issues

☐Alzheimer’s ☐Addiction ☐ Colitis ☐Insomnia ☐Gout ☐Parkinson’s

☐Bronchitis ☐ Schizophrenia ☐Heart Murmur ☐Glaucoma ☐Lupus ☐Osteoporosis

or Osteopenia

☐Chronic Fatigue ☐Eating Disorder ☐Heart Attack ☐Cataract ☐Multiple Sclerosis ☐Pneumonia

☐Cholesterol high ☐Epilepsy/Seizure ☐Angina ☐Concussion ☐Sojourns

Syndrome ☐Tuberculosis

☐Hemorrhoids ☐Varicose Veins ☐Bladder Issues ☐Eczema ☐Psoriasis ☐Acne

Other, not listed:

Female History: Please note: “P” = “Past”, “C” = “Current”, “N” = “Never”

When was you last Female exam?

Period Irregular Endometriosis Ovarian Cyst Uterine Cancer Menopause

Heavy Period Fibrocystic Breast Vaginal Infection Ovarian Cancer Pregnancy #

Fibroids PMS Breast Cancer Abnormal Pap Birth #

)

Are you chemically sensitive to odors? If "YES", explain:

BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.

HEALTH PROFILE

NAME DATE Rate each of the following symptoms upon your typical health profile for:

Point Scale 0 Never or Almost never have the symptom 3 Frequently have it, effect is not severe

1 Occasionally have it, effect is not severe 4 Frequently have it, effect is severe

2 Occasionally have it, effect is severe HEAD HEADACHES DIGESTIVE NAUSEA, VOMITING FAINTNESS TRACT DIARRHEA DIZZINESS CONSTIPATION INSOMNIA BLOATED FEELING TOTAL BELCHING, PASSING GAS

EYES WATERY OR ITCHY EYES HEARTBURN SWOLLEN, REDDENED OR STICKY EYELIDS INTESTINAL / STOMACH PAIN

BAGS OR DARK CIRCLES UNDER EYES TOTAL

BLURRED OR TUNNEL VISION (Does not include near or far-sightedness) JOINTS/ PAIN OR ACHES IN JOINTS

TOTAL MUSCLES ARTHRITIS EARS ITCHY EARS STIFFNESS OR LIMITATION OF MOVEMEMENT

EARACHES, EAR INFECTIONS PAIN OR ACHES IN MUSCLES

DRAINAGE FROM EAR FEELING OF WEAKNESS OR TIREDNESS

RINGING IN EARS, HEARING LOSS TOTAL TOTAL WEIGHT BINGE EATING/DRINKING

NOSE STUFFY NOSE CRAVING CERTAIN FOODS

SINUS PROBLEMS EXCESSIVE WEIGHT HAY FEVER COMPULSIVE EATING SNEEZING ATTACKS WATER RETENTION EXCESSIVE MUCOUS FORMATION UNDERWEIGHT TOTAL TOTAL MOUTH/ CHRONIC COUGHING ENERGY/ FATIGUE, SLUGGISHNESS

THROAT GAGGING, FREQ. NEED TO CLEAR THROAT ACTIVITY APATHY, LETHARGY SORE THROAT, HOARSENESS, LOSS OF VOICE HYPERACTIVITY SWOLLEN OR DISCOLORED TONGUE, GUMS, LIPS RESTLESSNESS CANKER SORES TOTAL TOTAL MIND POOR MEMORY SKIN ACNE CONFUSION, POOR COMPREHENSION

HIVES, RASHES, DRY SKIN POOR CONCENTRATION

HAIR LOSS POOR PHYSICAL COORDINATION

FLUSHING, HOT FLASHES DIFFICULTY IN MAKING DECISIONS

EXCESSIVE SWEATING STUTTERING OR STAMMERING TOTAL SLURRED SPEECH HEART IRREGULAR OR SKIPPED HEART BEAT LEARNING DISABILITIES

RAPID OR POUNDING HEARTBEAT TOTAL

CHEST PAIN EMOTIONS MOOD SWINGS TOTAL ANXIETY, FEAR, NERVOUSNESS

LUNGS CHEST CONGESTION ANGER, IRRITABILITY, AGRESSIVENESS

ASTHMA, BRONCHITIS DEPRESSION SHORTNESS OF BREATH TOTAL

DIFFICULTY BREATHING OTHER FREQUENT ILLNESS TOTAL FREQUENT OR URGENT URINATION

GENITAL ITCH OR DISCHARGE

GRAND TOTAL TOTAL

BREAKTHROUGH MEDICINE HISTORY INTAKE FORM 4/17 REVISED.

FEMALE HORMONE SURVEY

Please score: BLANK= No Symptoms. 1-5 ( 1=Mild 5=Severe )

Hot Flashes

Night Sweats

Irritability

Mood Swings

Weepy

Irregular Periods

Heavy Periods

Bleeding between periods

Low sex drive

Lumpy breasts

Unable to reach orgasm

Painful intercourse

Lack of vaginal lubrication

Breast tenderness

Drooping breasts

Sleep problems

Anxiety or panic attacks

Depression

Loss of motivation

Feeling apathetic

Fatigue

Memory loss

Thinning hair

Dry skin

Cellulite

Decreased muscle strength

Fluid retention

Headache

Joint pain

Muscle pain

Urinary incontinence

Acne

Facial hair growth

Constipation

Food Cravings

Vaginal Discharge

Vaginal Itching

TOTAL

NAME DATE