Martin Keane, ap, mmq, cch



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Martin Keane, AP, MMQ, CCH
1432 Dr Martin Luther King Jr. Street North

St. Petersburg, FL 33704

(727) 821-7771 (office) (727) 821-6914 (fax) info@classicalmedicine.net
All information will be held in the strictest confidence. Feel free to add details not covered.
Name:

Mailing Address:

City, State, Zip:
Preferred Phone: Secondary Phone:

Fax:


email address:

Birth date:

Height & Weight:

Emergency Contact:

(Name & Number)
Referred by:

MAJOR COMPLAINTS:


What diagnosis, if any, have you been given?

Diseases (check all that apply & any treatments)

( ) Cancer ( ) Diabetes ( ) Hepatitis

( ) Heart Disease ( ) Sexually Transmitted Diseases ( ) High Blood Pressure

( ) Thyroid Disease ( ) Seizures

( ) Reactions to childhood, tourist or military vaccinations

( ) Other (please specify)
Surgeries (include year):
Significant Trauma: (Describe accidents, falls, etc., with dates, treatment, results)
Allergies:

Family Medical History: (Please explain and identify family member in relation to you)

( ) Cancer ( ) Diabetes

( ) Allergies ( ) Heart Disease

( ) Asthma ( ) High Blood Pressure

( ) Stroke ( ) Seizures

( ) Other
Medicines taken within the last two months (including vitamins, drugs, herbs, etc.):
How many cigarettes do you smoke a day?

How much coffee, tea or cola do you drink a day?

How much alcohol do you drink during a typical week?
PLEASE EXPLAIN if you have had any of the following within the last 3 months:

GENERAL:

( ) Poor Appetite ( ) Fevers ( ) Fatigue

( ) Strong Thirst (cold/hot drinks) ( ) Poor Sleeping/Trouble Sleeping ( ) Night Sweats

( ) Sweating Easily ( ) Chills ( ) Food Cravings

( ) Localized Weakness ( ) Change in Appetite ( ) Tremors

( ) Bleed or Bruise Easily ( ) Poor Balance ( ) Weight Gain

( ) Peculiar Tastes or Smells ( ) Weight Loss ( ) Energy Drop*

( ) Cravings (all that apply): *Time of day?

Sugar Salt Sour Spicy Fats


SKIN AND HAIR:

( ) Rashes ( ) Ulcerations ( ) Hives

( ) Itches ( ) Eczema ( ) Pimples

( ) Dandruff ( ) Loss of Hair ( ) Recent Moles

( ) Change in Hair or Skin Texture

Any other hair or skin problems?


EAD, EYES, EARS, NOSE AND THROAT:

( ) Dizziness ( ) Concussion/s ( ) Migraines

( ) Glasses ( ) Eye Strain ( ) Eye Pain

( ) Poor Vision ( ) Night Blindness ( ) Color Blindness

( ) Cataracts ( ) Blurry Vision ( ) Ear Aches

( ) Ringing in Ears ( ) Poor Hearing ( ) Spots in Eyes

( ) Sinus Problems ( ) Recurrent Sore Throats ( ) Nose Bleeds

( ) Grinding Teeth ( ) Sores on Lips or Tongue ( ) Facial Pain

( ) Teeth Problems ( ) Clicking Jaw

( ) Headaches - Where and When? Any other head or neck problems?

CARDIOVASCULAR:

( ) High Blood Pressure ( ) Low Blood Pressure ( ) Chest Pain

( ) Irregular Heartbeat ( ) Dizziness ( ) Fainting

( ) Cold Hand or Feet ( ) Swelling of Hands ( ) Swelling in Feet

( ) Blood Clots ( ) Difficulty in Breathing ( ) Phlebitis
Any other heart or circulatory problems?
RESPIRATORY:

( ) Cough ( ) Coughing Up Blood ( ) Asthma

( ) Bronchitis ( ) Pain with Deep Breaths ( ) Pneumonia

( ) Difficulty Breathing Lying Down ( ) Production of Phlegm - What color?


Any other lung problems?
GASTROINTESTINAL:

( ) Nausea ( ) Vomiting ( ) Diarrhea

( ) Constipation ( ) Gas ( ) Belching

( ) Black Stools ( ) Blood in Stools ( ) Indigestion

( ) Bad Breath ( ) Rectal Pain ( ) Hemorrhoids

( ) Abdominal Pain or Cramps ( ) Chronic Laxative Use


Any other problems with your stomach or intestines?

GENITO-URINARY:

( ) Pain on Urination ( ) Frequent Urination ( ) Blood in Urine

( ) Urgency to Urinate ( ) Unable to Hold Urine ( ) Sores on Genitals

( ) Decrease in Urine Flow ( ) Kidney Stones ( ) Impotency

( ) Waking Up at Night to Urinate - How frequently?


Any particular color to your urine?
Any other problems with your genital or urinary system
REPRODUCTIVE AND GYNECOLOGIC:

Pregnancies:____________ Date of Last Menses:________ ( ) Irregular Periods

Births: ____________ Duration of Menses:_________ ( ) No Periods

Miscarriages:____________ Days between:______________ ( ) Breast Lumps/Pain

Abortions:____________ Flow: ( ) Heavy ( ) Light

( ) Chronic Yeast Infections Date of Last PAP:____________

Clots: ( ) Dark ( ) Red ( ) Menopause - Age:_____

Birth Control (What type? For How Long?):

Pain throughout Cycle (Check all that apply): ( ) Beginning ( ) Ending ( ) Ovulation

Vaginal Discharges/Leucorrhea (please describe):

PMS Changes in Body & psyche (When? Symptoms?):

Other Conditions:

MUSCULOSKELETAL:

( ) Neck Pain ( ) Muscle Pains ( ) Knee Pain

( ) Back Pain ( ) Muscle Weakness ( ) Foot/Ankle Pains

( ) Hand/Wrist Pain ( ) Shoulder Pain ( ) Hip Pain


Any other joint or bone problems?

NEUROPSYCHOLOGICAL:

( ) Seizures ( ) Dizziness ( ) Loss of Balance

( ) Areas of Numbness ( ) Lack of Coordination ( ) Poor Memory

( ) Concussion ( ) Depression ( ) Anxiety

( ) Bad Temper ( ) Low Tolerance for Stress


Have you ever been treated for emotional problems?


Share with your friends:


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