Wellness & Rejuvenation Center

WELLNESS & REJUVENATION CENTER PATIENT’S RECORD

NAME: ______Date: ______ADDRESS: ______AGE: _____ SEX: ____ STATUS: _____ CITIZENSHIP: ______Tel#: ______

SOURCE OF REFERRAL: ______SOURCE OF HISTORY: ______CHIEF COMPLAINT: (What, When it started, How long, Solution Taken) ______MEDICAL HISTORY: (What Illness, When, Who/Where Treated, Treatment Done) ______FAMILY HISTORY: (Relationship, Cause of Death/What Illness, When) ______HISTORY OF ALLERGY: (What, When, Who/Where Treated, Treatment Done) ______PSYCHOSOCIAL & DIETARY HISTORY: Religion: ______Occupation: ______Smokes? _____ What: ______How many: ______Drinks Milk? _____ What: ______How many times: ______Exercises? _____ What: ______How long: ______What food are you fond of eating? ______Sleep Patterns: ______Are you on any other health therapy now? _____ What: ______Describe: ______Home Situation & Daily Life: (Who lives with you? Who helps you when you’re sick or need assistance? Describe them and also your friends. What is your daily routine like from time of arising to bedtime?) ______

======I certify that I have read and understand all the questions set forth and the information provided are true and correct to the best of my knowledge.

After knowing & understanding the treatment approach use in this system of medical management, I also on my own volition subject myself for treatment.

______Patient’s Signature PERTINENT PHYSICAL FINDINGS: General Survey: Height: _____ Weight: _____ Sensorium: (Alert, Drowsy, Lethargic/Stuporous, Semicoma or Coma/Comatose) Attention Span: (Confused, Grossly disoriented, Demented) Orientation: to Time? ______Place? ______Person? ______Communication Ability: Can express or communicate thoughts or needs? ___ (Verbally, in Writing or by Gestures). If able to communicate verbally, is it (Clear or Dysarthria, Coherent or Incoherent), Can understand and respond appropriately to question or task? ______What form of communication is he responsive to? (verbal, gestural or written). If able to comprehend, can follow instructions? ______Physique or built of patient: (Endomorphic, Ectomorphic, Mesomorphic, Sthenic, Hypersthenic, Hyposthenic or Asthenic). Nutritional Status: (Well-nourished, Overnourished/Obese, Undernouriished) If undernourished, what degree? ______Development: (Well-developed, Fairly developed, Underdeveloped) Ambulation Status: (Bedridden, Wheelchair-borne, ambulant with or without assistance) Severity of Illness: (Presence or absence of an apparent distress and its relative intensity) If having difficulty in breathing, is respiratory distress (mild, moderate or severe). In pain? ___ intensity? Depressed? _____ intensity? _____ Vital Signs: Usual BP: ______BP: ______HR: ______PR: ___ Rhythm: ______RR: __  Skin: (Rashes, lumps, sores, itching, dryness, color change, changes in hair & nails) ______ Head: (Headache, head injury) ______ Eyes: (Vision, glasses or contact lenses, pain, redness, tearing, blurring, double vision, spots or specks, glaucoma, cataracts, last eye examination) ______ Ears: (Decreased hearing, tinnitus, vertigo, earaches, infection, discharges, hearing aids) ______ Nose & Sinuses: (Frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble) ______ Mouth & Throat: (Dry mouth, sore tongue, frequent sore throats, hoarseness, condition of teeth & gums, bleeding gums, dentures?, if any, how they fit & last dental examination) ______ Neck: (Lumps, “swollen glands”, goiter, pain or stiffness) ______ Breast: (Lumps, pain or discomfort, nipple discharge, self-examination?) ______ Respiratory: (Cough, sputum (color & quantity), hemoptysis, wheezing asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy; last x-ray film) ______ Cardiac: (Heart trouble, high blood pressure, rheumatic fever, heart murmur, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past ECG or other heart test) ______ Gastrointestinal: (Trouble swallowing, heartburn, appetite, nausea, vomiting, regurgitation, vomiting blood, indigestion; Frequency of vowel movements, color & size of stools, change in bowel habits, rectal bleeding or black tarry stools, hemorrhoids, constipation, diarrhea; Abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver or gallbladder trouble, hepatitis) ______ Urinary: (frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of urinary stream, hesitancy, dribbling, incontinence, urinary infections, stones) ______ Genitals: (Discharge, itching, sores, lumps, STD and treatments done, Sexual preference, interest, function, satisfaction and problems; MALE: Hernia? FEMALE: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding, bleeding between periods or after intercourse, last menstrual period; age at menopause, menopausal symptoms, postmenopausal bleeding) ______ Peripheral Vascular: (Intermittent claudication, leg cramps, varicose veins, past clots in the veins) ______ Musculoskeletal: (Muscle or joint pains, stiffness, arthritis, gout, backache. If present describe location & symptoms, i.e.; swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion or activity) ______ Neurologic: (Fainting, blackouts, seizures, weakness, paralysis, numbness, tingling or “pins & needles”, tremors, other involuntary movements)______ Hematologic: (Anemia, easy bruising or bleeding, past transfusions and any reactions)______ Endocrine: (Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria) ______ Psychiatric: (Nervousness, tension, mood including depression, memory) ______======DIAGNOSIS: ______INITIAL TREATMENT: ______WELLNESS & REJUVENATION CENTER FOLLOW-UP RECORD

NAME: ______Page: ______

======PATIENT FEEDBACK/COMPLAINT: Date: ______BP: ______Weight: ______Height: ______ASSESSMENT/FOLLOW-UP TREATMENT: ______PATIENT FEEDBACK/COMPLAINT: Date: ______BP: ______Weight: ______Height: ______ASSESSMENT/FOLLOW-UP TREATMENT: ______PATIENT FEEDBACK/COMPLAINT: Date: ______BP: ______Weight: ______Height: ______ASSESSMENT/FOLLOW-UP TREATMENT: ______PATIENT FEEDBACK/COMPLAINT: Date: ______BP: ______Weight: ______Height: ______ASSESSMENT/FOLLOW-UP TREATMENT: ______PATIENT FEEDBACK/COMPLAINT: Date: ______BP: ______Weight: ______Height: ______ASSESSMENT/FOLLOW-UP TREATMENT: ______PATIENT FEEDBACK/COMPLAINT: Date: ______BP: ______Weight: ______Height: ______ASSESSMENT/FOLLOW-UP TREATMENT: ______