1226 Michigan Avenue

East Lansing, MI  48823

517-333-7270 – Phone

517-333-1801 – Facsimile

Email: info@wycoffwellness.com

Women’s Questionnaire – Patient Information

Name:  

Address:  

City:    

State:  

Zip:  

Phone:  

Home:  

Work:  

Cell:  

Email:  

Birthdate:

Age:

What is your occupation?  

Primary Concern

1.  What is your primary concern? 

What kind of physicians have you seen for your health problem(s)? 

Allergy Treatment

Yes 

No

Please check all appropriate boxes

Have you been evaluated by an allergist?

What year? 

       Have you been tested for food allergies?

       Have you been tested for inhalant allergies?

Did you receive allergy immunization injections?

No of Yrs.

Discontinued in?

Did you receive sublingual drops?

No of yrs.

Discontinued in?

Past Medical History

Smoking

Yes

No

Please check all appropriate boxes

Do you currently smoke or did you ever smoke regularly

Pks per

day:

No. of

yrs:

What year did you quit?

Year:

Do you consume caffeinated beverages regularly?

# Per day/

wk:

No of

Yrs:

Do you consume alcoholic beverages regularly?

# Per day/

Wk:

No of

Yrs.

Do you consume carbonated beverages regularly?

# Per day/

Wk:

No of

Yrs.

Yes

No

Illnesses

Year

Yes

No

Illnesses

Year

Cancer

Kidney Disease

Chronic Fatigue Syndrome

Lupus

Colitis

Mitral Valve Prolapse

Diabetes

Mononucleosis

Elevated Cholesterol

Multiple Sclerosis

Elevated Triglycerides

Oral yeast/Mouth Infection

Fibromyalgia

Pelvic Inflammatory Disease

Gall Bladder Disease

Pneumonia

Heart Disease

Seizures

Hepatitis

Sexually Trans. Disease

Shingles

Herpes

Sleep Apnea

HIV Positive

Stroke

Hypertension

Tuberculosis

Hyperthyroidism

Ulcerative Colitis

Hypothyroidism

Irritable Bowel Syndrome

Lifetime Antibiotic Use:

Approximately how many times have you used antibiotics over the past:

1 Yr:                No. x/yr.

5 yrs:               No. x/yr.

10 y:               No. x/yr.

20 yrs:                 No. x/yr.

Yes

No

Please answer all appropriate boxes

Was there a time in the past when you used antibiotics for 30 days or longer continuously for acne or other illness?

     If yes, for what illness(es):

Year:

     How long did you take the antibiotics?

# Yrs:

     If for acne, did you take Accutane?

For how long?

Drug Allergies:  List all medications to which you are allergic.

1.

2.

3.

4.

5.

6.

Surgical Procedures:

What surgeries have you had?

Year (s)

Food

Daily

Wkly

{0}

Food

Daily

Wkly

{0}

Wheat Products

Corn Products

Dairy

Milk

Beef

Chicken

Soybeans

Starches

Are there any foods to which you have an adverse reaction?

Symptom

Yes

No

Do you have any cravings for sweets, breads or salty foods?

Condition

Mother

Father

Siblings

Children

Grandparents

Alcoholism

Arthritis

Asthma

Hay Fever

Cancer