Patient History Form - Page 3 of 3

P. Anthony Chapdelaine, Jr., MD, MSPH, Founder and Medical Director
General And Alternative Medicine
229 Ward Circle Suite B12
Brentwood, TN 37027
(615) 377-6767

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SYMPTOMS

Do you have any problems with fatigue or low energy?__________
Is there a particular time that seems worse? _______________
What is your usual temperature (unknown, low, normal, high)? ______
Describe sleep (OK, waking often etc.) ____________________________

Which of these are currently concerns or problems?(Circle)

Nervousness – Depression – Fears - Shyness
Sexual problems - Suicidal thoughts – Finances - Anger
Stress/Anxiety - Tiredness/fatigue - PMS
Career choices - Pain - Regrets - Drug use
Self control - Work - Inferiority - Legal matters
Enemies - Grieving - Making decisions - Separation
Alcohol use - Unhappiness - Unpleasant memories
Relaxation - Memory - Loneliness - Temper
Marriage - Thoughts (repeated) - Social Skills – Dizziness
Divorce – Friends – Headaches – Ambition
Children – Parenting – Motivation - Concentration/focus

Additional comments or concerns not addressed above
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FEMALES ONLY

Menstrual cycle: regular  irregular                painful                   heavy
First day of last menstrual period _____________

Menopausal (no longer cycling) (for how long?) _________________________

Hysterectomy (total or partial and year)____________________

Last Pap ___________ Results _____________
Number of Pregnancies _____ Children (ages)____________________

Are you now taking birth control pills?________________