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ONLY FOR NEW TOXICOLOGY
PATIENTS
Please print or write legibly! It is extremely important
that you complete this form and bring it with you to our office on
the day of your appointment!
If you do not have enough room to fully
answer any questions, please feel free to continue your response on
the blank sheets attached, making sure to indicate
“See Attached” and then note the specific section and question
number as you begin writing on the blank
sheet.
Patient’s Full
Name:
Date:
Section I: INFANCY (from birth to
age 2)
1.
When and where were you
born?
2. If you have/had siblings, where were you
in the birth order (example, 3rd of 3
children)?
3.
If your mother had any major health problems during pregnancy
or delivery of you, please
explain?
4.
Were you breast fed or bottle
fed?
5.
Was your mother exposed to any unusual chemicals or drugs
during pregnancy or during your
infancy?
6.
Were you exposed to any unusual chemicals during your
infancy?
7. Hospitalizations and surgery from birth to
age 2 (list age and brief
description):
8. Please circle any of
the following which characterized you or your environment from birth
to age
2:
full term Frequent
colds or flu
premature
Congenital abnormalities
jaundice
Failure to thrive/ development
problems
colic Other
serious illness
thrush Parents
smoked
ear infections
Abusive or alcholic
parents
frequent antibotics
Pneumonia
other:
9.
Major illnesses or medical conditions from birth to age 2
(list age and brief
description):
10.
Please describe any major accidents/ injuries (list age and
description):
11.
Did you have any allergies to formula, food, beverages, or
medications from birth to age 2? If so, please
describe.
12.
Please indicate the occupations of your parents during your
childhood.
Section II: Childhood (age
2-12)
1.
Where did you live during this childhood period? Only list places you lived
more than 6 months. If
your family moved frequently, indicate that rather than listing each
place.
2.
Were you exposed to any farm chemicals (pesticides,
herbicides, etc.), household pesticides, industrial chemicals, or
any other unusual toxic substances during childhood? If so, please
explain.
3.
Were you exposed to an unusual amount of other chemicals as a
child (e.g., paints, paint thinners, refinishing products, solvents,
new construction materials such as would be found in a brand new
house, etc.)”
4.
Did you live in or near an industrial area? If so, please
describe.
5.
Did you live on or near a golf course? If so, for how
long?
6. Please indicate which, if any, of the
following problems/ conditions developed when you were a child (
ages 2-12) by indicating the approximate age of
onset.
Age
____
Frequent colds of flu
____
Behavior problems
____
Tonsilits
____
Attention deficit
syndrome
____
Bronchitis or asthma
____
Hyperactivity
____
Ear infections
____
Difficult learning
____
Measles
____
Frequent headaches
____
Mumps ____
High # of
absences of school
____
chicken pox
____
Upset stomach, indigestion, stomach
pain
____
Whopping cough
____
Pneumonia
____
Frequent antibotic use
____
fever blister
____ Strep
Infections
____
Parents smoke
____
Seasonal allergies or hayfever
____
abusive or alcoholic parents
____ Significant
dental work ____
skin
disorders
____
other:
7.
Hospitalizations and surgery as a child (list age and brief
description):
8.
Major illness or medical conditions as a child (list age and
brief description):
9.
Please describe any major accidents/ injuries (list age and
description):
10.
Allergies to molds, dust, animal danders, pollen, beverages,
foods, or medications as a child? If so please describe and
include information on any know seasonal
pattern:
11.
List foods you loved and craved, or foods you hated and
avoided, as a child:
12. Please list and explain any medications/
drugs (prescription or over the counter) taken frequently or
regulary as a child:
SECTION III: FOR FEMALE PATIENTS
ONLY
1.
At what age did your menstrual cycle
begin?
2.
Please describe any problems associated with your period in
the beginning.
3.
Did you take birth control pills as a teenager? If so indicate age, reason
and for how long.
4.
Please list any pregnancies you had during your teenage
years.
SECTION IV: ADOLESCENCE/ YOUNG
ADULTHOOD (AGES 13-20)
1.
Where did you live during these years? (Please list dates and
locations of places you lived more than 6
months.)
DATES (from..to)
Location
2.
Were you exposed to any farm chemicals (pesticides,
herbicides, etc.), household pesticides, industrial chemicals or any
other unusual toxic substances during adolescence? If so, please
explain.
3.
Were you exposed to an unusual amount of other chemical (e.g.
paints, paint thinners, refinishing products, solvents new
construction materials such as would be found in a brand new house,
etc)? If so please
describe.
4.
Did you live in or near industrial area? If so please
describe.
5. Did you live near or on a golf course? If
so for how long?
6.
Did you take any (ilicit) drugs or abuse alcohol as an
adolescent/ young adult?
If so please explain.
7.
Did you smoke cigarettes? Include age started, total
number of years smoked (if you continue to smoke please indicate “to
present”), and how many pack/ day on the
average.
8.
Did you work during these years(high school or early
college)? Please list
all jobs during adolescense/ young adulthood held for more than 6
months.
Dates
Type of Business
Position held
Exposures
Protective gear
used
9.
Circle any of the following to which you were exposed between
ages 12 and 20 at school or
home:
Pesticides, herbicides
Computer screen
Daily x-rays or radiation High
intensity noise
Fumes and dusts paint
fumes
Metal dusts Excessive
heat and cold
Tobacco smoke
Emotional stress
Molds High
voltage power
other:
10.
Please indicate which if any of the following problems/
conditions developed when you were an adolescent by indicating the
approximate age of onset.
AGE
AGE
____
Frequent colds of flu
____
Behavior problems
____
Tonsilits
____
Attention deficit
syndrome
____
Bronchitis or asthma
____
Hyperactivity
____
Ear infections
____
Difficult learning
____
Measles
____
Frequent headaches
____
Mumps
____
High # of absences of
school
____
chicken pox
____
Upset stomach, indigestion, stomach
pain
____
yeast/ fungal infections
____
Pneumonia
____
Frequent antibotic use
____
fever blister
____ Strep
Infections
____
Acne
____
Seasonal allergies or hayfever
____
abusive or alcoholic parents
____ Significant
dental work
____
skin disorders
11.
Hospitaliztions and surgery (including surgical implants)
during this time period (13-20) list age and
description.
12.
Please describe any major accidents /
injuries.
13.
Allergies to molds, dust, animal danders, pollen, beverages,
food or medications as young
adult?
14.
Please list and explain any medications/ drugs (prescription
and over the counter) taken frequently or regularly during these
years:
SECTION V: CURRENT (AGES
20-PRESENT)
1.
Where did you live during these years? Please list dates and
locations of places where you lived more than 6 months, including
your present home.)
Dates (from...to)
Location
2.
Were you exposed to any farm chemicals (pesticides,
herbicides, etc.), household pesticides, industrial chemicals, or
any other unusual substances since age 20? If so please
explain.
3. Were you exposed to an unusual amount of
other chemicals (paints, paint thinner new construction materials?
If so please describe.
4.
Did you/ do you live in or near an industrial
area?
5.
Did you / do you live on or near a golf
course?
6.
Did you/ do you take any(illicit) drugs or abuse alcohol
since age 20? If so
please explain.
7.
Did you begin smoking cigarettes during this period? Include age started, total
number of years smoked (if you continue to smoke, please indicate
“to present”) and how many packs/day on the
average.
8.
Please list all jobs since age 20 held for more than 12
months including your current job
.
Dates
Type of Business
Position Held
Exposures
Protective gear used
9.
Circle any of the following to which you were exposed since
age 20 at school or at home:
pesticides
computer screen
daily x-rays
high intensity noise
fumes and dust
paint
fumes
metal dusts
excessive heat and cold
solvents
emotional stress
tobacco smoke
high voltage
power
molds
other
10.
Please indicate which, if any, of the following problems/
conditions developed after age 20 by indicating the approximate age
of onset.
AGE
AGE
____
Frequent colds of flu
____
Behavior problems
____
Tonsilits
____
Attention deficit
syndrome
____
Bronchitis or asthma
____
Hyperactivity
____
Ear infections
____
Difficult learning
____
Measles
____
Frequent headaches
____
Mumps
____
High # of absences of
school
____
chicken pox
____
Upset stomach, indigestion, stomach
pain
____
Whopping cough
____
Pneumonia
____
Frequent antibotic use
____
fever blister
____ Strep
Infections
____
Parents smoke
____
Seasonal allergies or hayfever ____
abusive or alcoholic
parents
____ Significant
dental work ____
skin
disorders
____
11.
Hospitaliztions and surgery (including surgical implants)
since age 20. List age
and describe.
12.
Please describe any major accidents/ injuries since age 20
(list age an description):
13.
Allergies to molds, dust, animal danders, pollen, beverages,
foods, or medications since age 20? If so please
describe.
14.
Please list and explain any medications/ drugs (prescriptions
and over the counter) taken frequently or regularly since age
20:
15.
Please list all vitamins /minerals/ nutritional supplements
that you are presently using. Indicate frequency and length of time
you have been taking them.
16.
Have you lived or traveled outside the US? If so please describe when
and where.
17.
Do you have any known or suspected current food allergies or
drug sensitivities? If
so, please explain.
18. Please explain any unusual weight
fluctuations since age 20.
19.
If you are or have been under the care of other physicians
for any major health problems, please indicate doctors name,
treatment, length, and results of
treatment.
20.
Please describe your family’s health status/ history, being
sure to list all members of your immediate family and all
significant health problems of each member. If family members is
deceased indicate cause of
death.
Example: mother– hypothyroid problems,
diabetes
Brother–excellent health
SECTION VI: FOR FEMALE PATIENTS
ONLY:
1.
Please indicate any problems with your menstrual cycle since
age 20.
2.
Did you / do you take birth control pills or other female
hormones since age 20?
If so indicate type and starting/ ending
dates.
3.
Please list any pregnancies you had since age 20, with
outcome of pregnancies (miscarriages, abortions, date of births and
birth weight of children).
4.
Explain any problems experienced during pregnancy and / or
delivery or your children.
5.
Any postpartum depression? If so please describe
severity and length of time.
6.
Any fertility problems?
If so please describe.
7.
Any vaginal yeast or bacterial infections since age 20? If so
please explain.
8.
If you suffer with PMS, please indicate the symptoms you
experience and the time during your cycle when you experience these
symptoms.
9.
Please indicate the starting date of your last
period.
SECTION VII: CURRENT HEALTH
CONCERNS
Please list the chief health
complaints which you would like Dr. Early to address:
1.
2.
3.
4.
5.
Please indicate who referred you to Dr.
Early
If you have had any bloodwork
done in the last six months, please bring copies with you as well as
any other medical documentation which you think Dr. Early should
see.
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