LAKEVIEW INTEGRATIVE MEDICINE

PATIENT MEDICAL HISTORY FORM

- BRIEF LIST OF CHIEF COMPLAINTS IN ORDER OF THEIR IMPORTANCE TO YOU.

- BRIEF LIST ALL DIAGNOSIS GIVEN TO YOU CHRONOLOGICALLY, AND YOUR PERSONAL OPINION

ABOUT THE DIAGNOSIS.

- LIST YOUR OPINION ON WHAT YOU THINK HAS HAPPENED TO YOUR HEALTH.

- LIST ALL HEALTH CARE PROVIDERS YOU HAVE CONSULTED, THEIR OPINIONS AND TREATMENT.

- LIST ANY TREATMENT, MEDICATION OR SUPPLEMENTS THAT HAVE IMPROVED YOUR HEALTH.

- LIST CHRONOLOGICALLY ANY MEDICATION YOU HAVE TAKEN IN THE PAST.

- LIST CHRONOLOGICALLY ANY SUGERIES YOU HAVE HAD.

- LIST CHRONOLOGICALLY ANY SIGNIFICANT LABORATORY AND IMAGING RESULTS.

- LIST CHRONOLOGICALLY ANY EXPOSURE TO ENVIRONMENTAL, INDUSTRIAL OR TOXIC

COMPOUNDS.

- LIST ANY HISTORY OF INFECTIONS (EXCLUDE COMMON COLD).