The Office of Dr. Mischa Grieder, N.D. at San Francisco Preventive Medical Group

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Ada Stokes
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1 The Office of at San Francisco Preventive Medical Group Medical History Form Date: DOB: Patient Name: Occupation: PCP: Referring Physician: Allergies: Drugs Asthma: Hay Fever Hives_ Environmental Allergies Other Allergies Past Medical History: Have you ever had any of the following diagnoses? If yes, please check the box. q ALS q Alzheimer s Disease q Anemia q Asthma q Autism q Baker s Cysts q Bell s Palsy q Bursitis (Where? ) q Carpel Tunnel Synd. q PANDAS q ME/CFS q Encephalitis q Fibromyalgia q Iritis q Meningitis q Multiple Sclerosis q Polymyalgia Rheumatica q Prostatitis q Psoriasis/Eczema q Tendonitis q TMJ q Heart Disease q Tuberculosis q Kidney Stones q High Blood Pressure q Positive TB Skin Test q Cancer q Rheumatic Fever q Stomach Ulcer q Stroke q Heart Murmur q Hepatitis q Convulsions q Enlarged Heart q Gallstones q Phlebitis q Pneumonia q Thyroid Trouble q Bleeding Disorder q Pleurisy q Diabetes q STI q Other_

2 Surgeries (Please give approximate date) q Tonsillectomy q Hysterectomy q Gallbladder q Hernia Repair q Biopsy q Splenectomy q Appendectomy q Ulcer Surgery q Joint Surgery q Other Other Hospitalizations or Accidents: Date Reason Immunizations (Give approximate dates) q Tetanus q Diphtheria q Polio q Childhood q Lyme q Hepatitis q Travel q Military q Other Women s Health: Are you currently, or think you may be pregnant? date of last period Pregnancies Miscarriages Live Births Age Menstruation Began Cycle Length Duration Irregular periods? Spotting between? Painful? PMS? Other Family Medical History: Father s Age Health Problems or Cause of Death Mother s Age Health Problems or Cause of Death Siblings their health Have any of your relatives had: (list who, ie: parent, grandparent, sibling, etc.) q Diabetes q Tuberculosis q Cancer q Allergies q Arthritis q Heart Disease q Bleeding Disorder q High Blood Pressure q Chronic Back Pain q Psoriasis q Other conditions not listed Page 2 of 11

3 Current Health Do you currently have any of the following? General q Fatigue q Fevers high low q Flu- like symptoms q Loss of voice/hoarseness q Sore Throats q Skin Rash q Swollen Glands q Recurring Nosebleeds q Goiter q Loss of Appetite q Hair Loss q Night Sweats q Unexplained Chills q Recent Weight Change Gastrointestinal & Urinary q Abdominal Pain q Frequent Indigestion q Trouble with Swallowing q Change in Bowel Habit q Constipation q Diarrhea q Bloody Bowel Movement q Diverticuloses q Irritable Bladder q Urinary Frequency q Urinary Retention q Frequent Urination at night q Blood in Urine q Slow Urinary Stream q Painful Urination q Liver Enlargement q Spleen Enlargement q Tenderness in Abdomen q Vomiting q Vomiting blood Heart and Lung q Abnormal echocardiogram q Chest Pain/Tightness q EKG Abnormalities q Heart Attack q Heart Palpitations q Skipped Heartbeats q High Blood Pressure q Mitral Valve Prolapse q Swelling of Ankles or Feet q Shortness of Breath q Wheezing q Frequent Coughing Dry or Productive q Coughing up Blood Eye and Ear q Blind Spots q Blurred Vision q Conjunctivitis q Diminished Periph. Vision q Double Vision Horizontal or Vertical q Drooping eyelids q Flashing Lights q Lazy Eye q Light Sensitivity q Optic Atrophy q Pressure behind Eyes q Uveitis q Vision loss/blindness q Eye pain q Ringing in the Ears q Hearing loss/deafness One ear or Both ears Musculoskeletal q Muscle Pain or Aches q Muscle Cramps q Stiff Muscles q Loss of Muscle Tone q Jaw Pain or Stiffness q Back Pain or Stiffness q Neck Pain q Joint Pain q Stiff Joints q Hand Pain and/or q Swelling q Elbow Pain and/or q Swelling q Shoulder Pain / Swelling q Hip(s) Pain / Swelling q Knee Pain / Swelling q Feet/Ankle Pain / q Swelling q Leg aches Reproductive q Breasts: Infections or discharge? q Loss of Libido (decreased sex drive/activity) q Pelvic Pain q Menstrual Irregularities - q Symptoms Worsen around Menstruation Cont d on following page Page 3 of 11

4 Neurological q Abnormal EEG q Anxiety Attacks q Burning Sensation: External Internal q Change in: Smell Taste q Confusion q Decreased Concentration q Dementia q Depression q Difficulty: Chewing Swallowing q Dizziness q Fainting q Fatigue q Hallucinations q Headache: Mild Severe q Migraine: With Aura q Involuntary Jerking q Irritability q Memory Problems q Meningitis q Mood Swings q Motion Sickness q Muscle Twitching Where? q Nightmares q Numbness Where? q Obsessive/Compulsive Behavior q Panic Attacks q Paranoia q Partial Paralysis Where? Neurological, cont d q Personality Change q Poor balance/difficulty walking q Restless Legs q Seizures Epileptic or Non- Epileptic q Sleep Disturbances: Falling Asleep Waking Frequently q Suicidal q Tearfulness q Tingling Where? q Tremors or Shaking q Weakness of Limbs q Unusual Clumsiness Special Children s Questions q Decreased Interest in Playing? q Poor School Performance? q When did he/she start whimpering/whining? Abnormal Lab Results Date / Lab q Pos. Lyme Elisa q Pos. Lyme WB IgG IgM q Pos. Lyme PCR q Pos. Lyme Culture q Other positive Lyme Tests: q Pos. Babesia q Pos. Erlichia q Pos. Bartonella q Pos. Mycoplasma q Elevated Liver Enzymes q Eosinophilia q Elevated ANA q Elev. SED rate q Elev. Cholesterol q Elev. Anticardiolipin q Rheumatoid Factor q VDRL (Syphillis) q Low IgG Serum q Low IgG Subclasses (1, 2, 3, 4) q CD57 q C4A q Methylation Panel Page 4 of 11

5 Toxicity Questionnaire Travel History: If you have traveled outside of the U.S., please list destinations, and if applicable, any related illness here: _ Place Date Travel related Illness? _ Place Date Travel related Illness? _ Place Date Travel related Illness? _ Place Date Travel related Illness? (Please use an additional sheet of paper if needed) Mold Exposure: q In home? If yes, age of home q Previous home? If yes, age of home q Workplace q School Infection History: Please indicate if you ve had these infections, and if so, how many times. q ear infections q strep q pneumonia q sinus q Frequent Antibiotic use? q Frequent use of Tylenol? Dental: q Amalgams how many q Root Canals q implants Any removed? q infections Medical: q Breast Implants q Other Implants Silicone or Saline? q Blood Transfusion q Plasma q Brain Injury (acquired or traumatic) q CNS Injury q Seizure q Stroke q Chemotherapy q Radiation Diet: Aspartame Intake: q Artificial Sweeteners q Diet Tea q Diet Soda High Fish Intake: q Tuna q Swordfish q Shark Other Foods: q Wild Game q Mushrooms Other: Pesticide exposure: q in home q outside home q golf q farm Hobbies: q Painting q Photo Development q Home Renovation q Firearms - Sanding off Paint? Radiation: q Workplace q Cancer Treatment q Radon in Home Electrical: q EMF q High Tension Wire q Workplace Computers q Transit Station q Well Water Consumption q Frequent Hot Springs Page 5 of 11

6 Health Summary Present Well Being: Poor Below Average Average Fairly Good Good Overall, how do you feel today? Most Prominent Symptoms: Date of First Symptoms: History of Tick Attachment? q Yes q No If yes, location on body: Date(s): Do you engage in any high- risk activities or hobbies? (ie: hiking, gardening, working with dogs) q Yes q No Do you have indoor/outdoor pets? Lifestyle: if yes, what? q Yes q No If yes: What type of animal? How long have you had? Do you let them sleep in your bed with you? Are they sick? q Tobacco use per day q Vaping q Alcohol use drinks per week Recreational Drugs: q Mushrooms q Cocaine q Ecstacy/MDMA q Marijuana q LSD q Caffeine (coffee, soda, tea) per day q Exercise per week q Milk glasses per week q Healthy diet? Your Birthplace: _ Other Cities/Towns where you have lived: Page 6 of 11

7 Past Physicians Please list the Doctors you have seen and reason seen Please include Naturopaths. Begin your list with most recent Doctor Doctor: Doctor: Doctor: Doctor: Doctor: Doctor: Doctor: Page 7 of 11

8 Past Medications: Please list past antibiotics/medications used to treat your current condition Medication Dosage/frequency How long Rx by 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Medical Tests Tests/Imaging Date Results 1) CT Scan of: 2) CT Scan of: 3) MRI: 4) MRI: 5) EEG: 6) Nerve Conduction: 7) Cardiac: 8) Tilt Table: 9) Lumbar Puncture: 10) Endoscopy: 11) Biopsy (of): 12) Neuropsych Eval: 13) Other: 14) Other: 15) Other: 16) Other: Page 8 of 11

9 Current Medications/Supplements Medication/Supplement Dosage/Frequency How Long Who 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) Page 9 of 11

10 Chronological Case History Please list event dates in bullet form chronologically, starting from earliest date and ending with most recent. Give short (2-3 sentences) summaries of each event. If important medical event details are incomplete, please bring copies of Doctor s office or hospital encounter information. Page 10 of 11

11 Chronological Case History, cont d Page 11 of 11

* * Patient Name: Date of Birth: Race: q CAUCASIAN q AFRICAN AMERICAN q HISPANIC q ASIAN

* * Patient Name: Date of Birth: Race: q CAUCASIAN q AFRICAN AMERICAN q HISPANIC q ASIAN 14 W. GORE STREET ORLANDO, FL 32806 PHONE 321.843.5001 FAX 321.843.5085 Date of Birth: Race: q CAUCASIAN q AFRICAN AMERICAN q HISPANIC q ASIAN Marital Status: q Married q Single q Widowed q Divorced q