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[DOC File]NEW PATIENT HISTORY FORM - ExcelSHE
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Alcoholism Allergies Anxiety Asthma Bipolar Disorder Bleeding Disorder Cancer: Breast Cancer: Cervical Cancer: Colon Cancer: Lung Cancer: Ovarian Cancer: Prostate Cancer: Other Clotting Disorder Depression Diabetes Drug problem Epilepsy/Seizures Headaches Heart Problems High Blood Pressure Migraines Schizophrenia Stroke Thyroid problem Other CURRENT MEDICATIONS Pharmacy _____ …
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[DOC File]Acu-Herb Elite
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Please list all your medications, including vitamins, minerals, herbs, and homeopathics: _____ Drug Name Dose Frequency Duration Any Benefits Any Side-Effects. Do you have any known allergies to drugs, foods, animals, materials, etc? _____ Substance Name . Reaction You Had
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The 5 Best Herbs for Spring Allergy Relief | Eat + Run | US News
List all medications with dosages, include over-the-counter medications and herbs) ... Asthma. Arthritis. Allergies. Alcoholism. Blood disorders. Cancer (specify type) Depression/anxiety. Other mental illness. Diabetes. Heart disease. High blood pressure. Stomach/intestinal disease. Stroke . Skin disease. Thyroid problem . Current Age(s)or Age at death. Other Health Care Providers: Do you have ...
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Southeast Medical Clinic Medical History Form
( Asthma ( COPD/Emphysema ( High Blood Pressure ( Tuberculosis ( Cancer ( Sarcoidosis ( Pulmonary Fibrosis MOST RECENT VACCINATIONS: Flu Vaccine _____ (Date) Pneumonia _____ (Date) Patient Intake Questionnaire. LIST CURRENT MEDICATIONS (Including Herbs and over the counter medications/ supplements) Medications Dose How Often **If list is longer than boxes provided, …
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[DOC File]Adult Health History Form
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Allergies (drugs, chemicals, foods) Medications taken in the past two months (vitamins, drugs, herbs, etc.) Have you ever been on a restricted diet? If yes, what kind? Do you smoke? If yes, how much? Please describe any use of drugs for non-medical purposes. Indicate any painful or distressed areas: Please specify if you have had (in the past three months): General. Poor sleeping Night sweats ...
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[DOC File]HERBS AND THE ZODIAK
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Diabetes Cancer High Blood Pressure Seizures Asthma Allergies Stroke Heart Disease Occupation. Occupational Stress (chemical, physical, physiological. Etc.) Do you have a regular exercise program? Please describe. Medicines taken within the last two months (Include vitamins, over-the-counter drugs, herbs, etc) Are you now or have you ever been on a restricted diet? _____ What kind ...
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[DOC File]Natural Therapy Center
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Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools MDH 3/2016 . 4. Ages 5-11 Parent/Guardian Asthma Questionnaire-Control. Please complete this form and return it to the school health office. The school nurse needs more information about your child's asthma or breathing problems. This will help us take care of your child at school. Date: Ages 5-11 Parent ...
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[DOC File]Health History Questionnaire - Word Format
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(name, dose, frequency) 6 1 7 2 8 3 9 4 10 5 11 include aspirin, herbs, vitamins, and over the counter medications. Allergies and Reactions:___ _____ _____ Family History: Please mark all that apply and WHO has had it (ie. Diabetes: mother)
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[DOCX File]Strong Internal Medicine - Welcome to URMC - Rochester, NY
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Herbs that normalize and restore body functions and increase the body's nonspecific resistance to stress: ginseng, licorice, nettle, astragulus. Alterative. They are also known as blood purifiers. Herbs that gradually restore health and vitality to the body: burdock, yellowdock, red clover, nettle, oregon grape, alfalfa, gota kola, marshmallow, ginseng, dong quai. Analgesic/Anodyne. Herbs that ...
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[DOC File]Patient Intake Questionnaire
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Current Herbs / Vitamins/ Homeopathy/ Supplements Dose Times / Day ... Children AIDS Alcoholism Allergies Alzheimer’s Anemia Arthritis Asthma Birth Defects Bleeding Disorder Breast Cancer Cancer Colon Cancer COPD Depression Diabetes Emphysema Epilepsy Glaucoma Heart Attack Heart Trouble High Blood Pressure IBS Kidney Disease Liver Disease Mental Illness Migraine Headaches …
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Herbs for asthma and allergies