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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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