Arvigo Patient Form Information form Reason For Visit Name First Last PhoneEmail Primary reason for visit: When did your first notice it? What brought it on? Describe any stressors occurring at the time What activities provide relief? what makes it worse? Is this condition getting worse? interfere with work sleep recreation Have you had massage/bodywork before? What type? Medical History Are you currently under the care of another health care provider(s)?Reason (s)Narrie(s) of Practltioner Address PhoneEmail Current Medications and /orSupplements/Remedles:Allergies: specify allergen and reaction:Surgical History (year and type) and/or Recent ProceduresHospitalizations:Accidents or TraumasFalls/lnjurles to Sacrum/head/tailbone (describe)Other: Please review and check the following : Headaches Numbness in feet or legs when standing Asthma Sore heels when walking Cold Hands or feet Anxiety Swollen ankles Depression Sinus Conditions Frequent Colds Sleep Disturbance Seizures Fainting Spells Low Back Pain Muscular Tension Skin Disorders Varicose Veins Hemorrhoids Sciatica Herniated/Bulging Discs Painful/Swollen Joints Artifical/Missing limbs High or Low Blood Contact Lenses Pressure Dentures/Partials Cancer (past or current) Review(mentioned above)Other (not mentioned above)Family History Still Living? Cause of Death/age of Major Health Issues Mother Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandfather Paternal Grandmother Digestion and EliminationTypical BreakfastTypical LunchTypical DinnerSnacksWater intake(glasses/day) Caffeine Do you use Tobacco? Yes No Quantity(/ppd) Alcohol? Yes No Quantity (ounces/ day). Marijuana? Yes No Quantity Other Have you been under treatment for substance use? What is the worst item In your diet What foods are your weakness Are you subject to binge eating? What foods Do you experience bloating/gas/burps after eating? What foods trigger this? How often are your bowel movements? Do Your StoolSinkFloatConstipation?Blood in stool?Mucus in stool?Pain when stooling?Other concerns: EMOTIONAL & SPIRITUALWhat is your opinion of yourself?If possible, please describe the most negative emotion you experienceWhen do you most often feel this emotionWhere are you?Do you pray to or have a spiritual practice On a scale of 1 -10 ( 1 being the lesser, 10 the greater) Please rate yourself:FaithHopeCharityGenerositySense of HumorSense of FunFearGriefOther (describe briefly),What are hobbies/ activities that provide you with a sense of pleasure and accomplishment .Describe your exercise routine (type, frequency),What changes would you like to achieve in-:6 months One Year Pregnancy History: Number of Pregnancies:Complications:Miscarriages:Terminations:Number of Births: Dates:Premature Births:Spotting during PregnancyWeak Newborns at BirthIncompetent CervixBriefly describe your experience with: Pregnancy Labor Birthing Post Partum Maternal Family History of (please mark) Infertility Fibroids Endometriosis PMS Menopause Cancer(type) Menstrual Problems Other Medications your mother took when she was pregnant with you (if any) Your Birth Trauma (if known)OtherRate your interest in Sex: High Moderate Low None Do you have or ever had difficulty experiencing orgasms Do you have a history of rape Trauma Incest lf so,-when Did you undergo counseling for this What was this like for you Menopause Age symptoms began: Are they getting worse Better Same Are you on/ or ever been on hormone replacement therapy? if So, how long Name and dose.Reason for stoppingAge of Mother at menopause Concerns/Experience. Check the following symptoms that apply to you: Hot flashes Vaginal Discharge Spotting Decreased Libido Insomnia Dry Vagina . Flooding Disturbed Sleep Pattern Fatigue Memory Loss Mood Swings Depression Anxiety Irritability Irregular Menses Painful Intercourse Increased Libido Additional Information you feel important your practitioner know that is not mentioned here:
