You have indicated
that "{concern}"
is your most important health problem. These questions will ask specific
questions about this health complaint. It is important that you enter
information on this page as it pertains to this complaint
only. You will be give the opportunity to enter information about your
other complaints when you finish this one.
The information you enter in this form is
completely confidential and is not shared with any other
source, unless requested in writing.
Major
Health Complaint Information:(
Required)
Your Major Complaint: {concern1}
When did you first notice {concern}?
Please state the reason {concern} started if known. If not known, state "I
don't know"
How has {concern} changed since then? Has it got better or worse or how is it
different since it started?
How often does
{concern} occur? (multiple selections are OK)
Additional Comments about the frequency
What makes {concern} worse? This could include any physical activities,
eating habits or other factors you are aware of.
What makes {concern} better? This could include any physical activities,
eating habits or other factors you are aware of.
Describe the quality
of symptoms you experience associated with {concern}.
(more than one choice is possible and you can add additional comments)
Does {concern} radiate anywhere?
If yes, where?
No
Yes
From "0" to "10" rate the
severity of {concern}
(0 is low 10 is intense)
Is {concern} consistently worse in the morning, noon, or evening? If yes
describe
No
Yes
How is {concern}
progressing? (Additional Comments OK)
What concerns you the most
about {concern}?
What is your goal
regarding {concern}?
Other comments about
{concern}?
Diagnostic Tests Performed
Record the date any of the following diagnostic tests that have been
performed FOR THIS COMPLAINT ONLY. If you are unsure of the date give your best estimate.
If you have not had any tests done for this complaint, check this box:
Other tests you have had
not listed above with date (specify)
If any of these tests you
checked above were
abnormal describe this here
Licensed Doctors / Physicians Seen
What has been done to date for this health problem
({concern})? (Include who has been seen, date, what was done,
and the results) Use a single box for each physician seen.
If you have not seen a doctor or physician for {concern},
check this box:
1st
Doctor/Physician Seen
Name of1st Physician Seen
Date Last Seen
What was done?
How would you
rate your results with this doctor? What benefits did you receive?
2nd
Doctor/Physician Seen
Name of 2nd Physician Seen
Date Last Seen
What was done?
How would you
rate your results with this doctor? What benefits did you receive?
3rd
Doctor/Physician Seen
Name of 3rdPhysicain
Seen
Date Last Seen
What was done?
How would you
rate your results with this doctor? What benefits did you receive?
4th Doctor/Physician Seen
Name of 4th Physician Seen
Date Last Seen
What was done?
How would you
rate your results with this doctor? What benefits did you receive?
Other Specialists Seen
Names of other specialists you have seen for other
health problems and the reason for seeing them (Cardiologist,
Psychiatrist, Naturopath, etc.)
If you have not seen any specialists for other health problems,
check this box:
Name of Doctor #1
Type of Doctor/Specialist
Seen for what health
problem?
Name of Doctor #2
Type of Doctor/Specialist
Seen for what health
problem?
Name of Doctor #3
Type of Doctor/Specialist
Seen for what health
problem?
Name of Doctor #4
Type of Doctor/Specialist
Seen for what health
problem?
This personal information will be saved into your MyHealth Record Profile. It
will also be used by your on-line doctor to make personalized recommendations.
Your history is also used to setup your free
My Journal to make tracking your progress even easier.
Knowing what activities, foods or other factors aggravate or help your health
problem may be a key in helping you determine how to manage it effectively.
Describing the quality of symptoms of a health problem when it occurs at its
worst, gives a doctor an idea of the type of body tissue involved.
For example a burning pain can indicate a blood vessel problem. A sharp pain can
indicate a pinched nerve or an inflammatory condition.
When a health problem occurs at specific times of the day this can indicate that
a specific organ system is under stress. For example, those people who feel
worse in the morning can have a toxic liver or large intestine; those people who
feel tired in the afternoons can suffer from low blood sugar.
Your doctor will want to know how this health problem is progressing. If getting
better, you are obviously doing something right. If staying the same or getting
worse, something will need to change as to how you're addressing the problem,
otherwise it will get worse.
Knowing what kind of tests that have already been done will guide your doctor in
a possible cause for the problem and greatly enhances helping you in determining
how much help you can get. It also will help determine what other health
specialists you may need to see.
A good doctor is like a detective. By knowing what kind of treatment you've
already received and the results, you can be guided to the best type of
treatment for your condition. Remember that this information is confidential.
Knowing the types of specialists you are seeing or have seen, will help your
doctor determine if one type of treatment is conflicting with another. Many
people take several medications that have side effects that interfere with other
medications. Since doctors don't always ask what you're taking, you can end up
with a self-induced health problem that you're not aware of.
Please review this form to be sure you have
answered the appropriate items and that your answers are accurate. Thank you
for choosing BecomeHealthyNow.com. We look forward to helping you achieve your
your health goals.
Please Note:
You have already
completed this sub-section of the MyHealth Analysis questionnaire. Your
answers are recorded above for you to review. If any of the data in the
form is NOT correct and
you need to CHANGE your answers, click the appropriate button
below. You
will then be allowed to make any necessary changes.
Please Note This Section is Complete:
You have already
completed this entire section of the MyHealth Analysis questionnaire. Your
answers are recorded above for you to review. If any of the data in this
subsection or any other subsection is NOT correct and
you need to CHANGE your answers, call your
on-line doctor, {doc_name} at {doc_phone}. He will make this entire
section incomplete and you will be able to make changes to any
sub-section. Your previous answers will NOT be lost, and you will be
able to review each sub-section and make changes.
Required)
