History and Current System Checklist 2011

Department to Contact:

Select Records Dr Norma Ann Faraone-Ledgard

First Name:

Middle Initial:

Last Name:

E-Mail Address:

Date:

Have you ever had or have a problem with Nutritional Disorders (vitamin deficiency, mineral deficiency, obesity, eating disorder)

Have you ever had or currently have a problem with Endocrine and Metabolic Disorders (hypothalamic-pituitary, thyroid, adrenal, etc)

Have you ever had or currently have a problem with Gastrointestinal Disorders (esophageal, gastritis, Ulcers, diarrhea, constipation, gastroenteritis, inflammatory bowel disease, diverticular disease, etc.)

Have you ever had or currently have a problem with Hepatic and Biliary Disorders (liver disease, alcoholic liver, hepatitis, diseases of the liver, liver tumors, etc.)

Have you ever had or currently have a problem with Musculoskeletal Disorders (connective tissue disease, arthritis, osteoarthritis, etc.)

Have you ever had or currently have a problem with Pulmonary Disorders (chronic obstructive airway, acute bronchitis, pneumonia, lung disease, etc.)

Have you ever had or currently have a problem with Ear, Nose, and Throat Disorders (otitis, dizziness, pharyngitis, tonsillitis, laryngitis, etc.)

Have you ever had or currently have a problem with Ophthalmologic Disorders (conjunctivitis, cataract, glaucoma, Macular Degeneration, etc.)

Have you ever had or currently have a problem with Dental and Oral Disorders (gingivitis, periodontitis, TMD, etc.)

Have you ever had or currently have a problem with Dermatological disorders (dermatitis, fungal infections, rosacea, psoriasis, malignant tumors)

Have you ever had or currently have a problem with Hematology and Oncology (anemia’s leukemia’s lymphomas, etc.)

Have you ever had or currently have a problem with Immunology, allergic disorders (transplants, hypersensitivity disorders, etc.)

Have you ever had or currently have a problem with Infectious Diseases (antibacterial drugs, antiviral drugs, herpes, HIV, AIDS, STD, etc.)

Have you ever had or currently have a problem with Neurologic Disorders (pain, headaches, seizures, stroke, movement disorders, MS, etc.)

Have you ever had or currently have a problem with Cardiovascular Disorders (arteriosclerosis, coronary artery diseases, arrhythmia’s, etc.)

Have you ever had or currently have a problem with Genitourinary Disorders (urinary incontinence, disorders of the penis and scrotum, dialysis, prostate disease, UTI’s, genitourinary cancer, etc.)

Have you ever had or currently have a problem with Gynecology and Obstetrics (PMS, Dysmenorrhea, Amenorrhea, Menopause, endometriosis, Breast Disorders, Infertility, Family Planning, Pregnancy, Postpartum, etc.)

Have you ever had or currently have a problem with Pediatrics (childhood infections, child abuse/neglect, cystic fibrosis, growth/development,etc.)

Have you ever had or currently have a problem with Pediatrics (childhood infections, child abuse/neglect, cystic fibrosis, growth/development,etc.)

*The following questions are for me to get to understand the way you feel, think and act. Please explain your answers to any that pertain to you as specific as you can. The more you tell me, the more I know, the better we can work on finding solutions to your problem(s).*

Have you ever had or currently have a problem with reading, math, spelling, or expressing yourself?

Have you ever considered yourself to be “clumsy”, poor in sports, poor handwriting?

Have you ever had or currently have a problem with stuttering?

Have you ever had or currently have a problem giving close attention to details or make careless mistakes?

Have you ever had or currently have a problem not following through on instructions?

Have you ever had or currently have a problem with staying still during a task?

Have you ever had or currently experience times when you would get into fights, pick on others, and hurt other/things/animals?

Have you ever had or currently have a problem with lying or stealing?

Have you ever been arrested? When? For What?

Have you ever had or currently have a problem with wetting the bed/clothing?

Have you ever had or currently have a problem with excessive worry from being separated from loved ones, or that harm would befall upon them?

Have you ever had or currently have a feeling of disturbances of consciousness (reduced clarity of awareness or a change in cognition)

Have you ever had a problem or currently have a problem with the ability to learn new information or recall previously learned information.

Have you used or do you currently use any of the following drugs (circle all that apply) Alcohol, Amphetamines, Caffeine, Cannabis, Cocaine, Hallucinogens, Inhalants, Nicotine, Opioids, Phencyclidine, Sedative, other

Have you ever been or are you currently in treatment for any of the above mentioned drugs?

Have you ever been successful in maintaining abstinence from any of the above mentioned drugs and for how long has the sobriety been for?

Have you ever felt or do you currently feel depressed/sad? Check if any apply:

Most of the day
Nearly every day
In cycles

Have you ever felt or do you currently feel extremely euphoric/high? Check if any apply:

Most of the day
Nearly every day
In cycles

Have you ever felt depressed/sad for about 2 years or more with little to no relief?

Have you ever attempted Suicide? If so when and how? Did you need hospitalization? Do you currently have feeling of Suicide? Do you currently have a plan of intent? Means?

Have you ever attempted to hurt someone else, have Homicidal feelings, rage toward someone? Do you currently have Homicidal feelings toward anyone?

Have you ever felt that you could hear voices, see things, feel things, etc. that only you can see, hear, feel?

Have you ever felt or do you currently feel that suddenly your heart was beating fast, sweating, trembling, chest pain, dizziness, loss of control, fear of dying all about the same time?

Yes or No: ,Yes;NoHave you ever been or are you currently afraid to leave your house in fear that something bad will happen for any length of time?

Have you found or do you find yourself doing the same behavior over and over and/or thinking the same thought over and over?

Have you ever experienced any traumatic or are you currently experiencing any traumatic event either by direct affliction, witnessed to, serious injury or illness?

Have you ever felt or do you currently feel a persistent avoidance of stimuli associated with the trauma?

Have you ever felt or do you currently feel detached or estranged from others after the traumatic event?

Have you ever felt or do you currently feel restlessness, easily fatigued, difficulty concentrating, irritable, muscle tension and sleep disturbance on or around the same time each month?

Have you ever had or do you currently have a complaint to a medical doctor, have had several test done and have had not diagnosis to this complain, and then have sought other medical doctors for their opinions to the same problem?

Have you ever felt or do you currently feel preoccupied with a part of your body that seems to you to be abnormal?

Have you ever received any tattoos or have had body piercing to your body? Have you ever removed any tattoos?

Have you tried or are you currently cutting a part of your body to help you in anyway? Are you performing or have you ever performed any self-mutilating behavior?

Have you ever or are you currently experiencing an inability to recall important personal information, or unexpected travel away from home not knowing how you arrived at that destination? (not recalling how you drove yourself someplace?)

Have you ever felt or do you currently feel the presence of two or more distinct identities of personality states within your body?

Have your ever experienced or are you currently experiencing difficulty enjoying or wishing to engage in a consensual sexual experience (if sexually active?)

Have you ever experienced or are you currently experincing genital pain associated with sexual intercourse (consensual)? Not related to sexual masochism or sadism

Have you ever refused or are you currently refusing to maintain your body weight, have an intense fear of gaining weight, have strict rules about eating?

Have you ever had or currently have a problem falling asleep , staying asleep, waking up early, etc or have you had problems with sleep walking?

Have you ever had or currently have intense aggressive episodes that have resulted in serious assaultive?

Have you ever had or currently have a problem with stealing, setting fires, gambling, etc?

Have you ever had or currently have problems adjusting to a particular situation resulting in significant impairment of social and occupational functioning?

Have you ever felt or do you currently feel a pervasive distrust and suspiciousness of others?

Have you ever felt or do you currently feel a pervasive pattern of detachment from social relationships, and show a lack of expressiveness?

Have you ever felt or do you currently feel a pervasive pattern of disregard for and violation of the rights of others occurring since age 15?

Have you ever felt or do you currently feel a pervasive pattern of instability of interpersonal relationships, self-image, and difficulty coping and marked impulsively?

Have your ever felt or do you currently feel a pattern of excessive emotionality and attention seeking?

Have you ever felt or do you currently feel a pervasive pattern of grandiosity, need for admiration or lack of empathy?

Have you ever felt or do you currently feel a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitive to negative evaluations?

Have you ever felt or do you currently feel a pervasive and excessive need to be taken care of that lead to submissive and clinging behavior and have an intense fear of separation?

Have you ever felt or do you currently feel a pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, at the expense of being flexible?

Please explain your Nutritional Regime, including when you eat, what you like to eat, etc.

Please explain your Exercise Regime, including when you exercise, what type of exercise you do, etc.

Please write anything else you would like me to know about yourself.

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