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227 West Janss Road Suite 135 Thousand Oaks, CA
Tel: (805) 373-2890
neuronoffice@gmail.com

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Schedule an Appointment

Home
Patient Info
Services
Age reversal therapy
Membership
Store
About Us
Contact Us

Neuron Medical Corporation is the neurology practice of Liliana Cohen, M.D., Paul Dudley, M.D. and naturopathic medical doctor Kristin Stiles Green, N.M.D. of Thousand Oaks, California.

LATEST NEWS

The science of OMICm Age with Harvard and TruDiagnostic researchers.
09/23/2023
Low Cholesterol: Is There a Neurologic Link?
06/11/2023

CONTACTS

227 West Janss Road Suite 135 Thousand Oaks, CA
neuronoffice@gmail.com
+1-(805) 373-2890

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Adult Health History Form Kristin Stiles Green, NMD, FABNO

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Adult Health History Form Kristin Stiles Green, NMD, FABNO

Please download,complete and print this form Health History Form_Adults_Dr Green_updated Jan 2024

Or complete the online form

Adult Health History Form Kristin Stiles Green, NMD NEW FORM

Adult Health History Form
Kristin Stiles Green, NMD, FABNO

* required field

First name

Last Name

Date

Age

Date of Birth

Gender

Address

City

State

Zip Code

Mobile Ph #

Home Ph #

E-mail address

Is any other family member already seeing us?

Person(s) to reach in an emergency

Relationship(s)

Phone #’s

May I thank someone for referring you to me?

PROACTIVE HEALTH CARE IS ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE UNDERSTANDING OF THE PERSON MENTALLY, PHYSICALLY, AND EMOTIONALLY.
PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE.

PLEASE, PRINT!
MARK ANYTHING YOU DON’T UNDERSTAND WITH A QUESTION MARK.

Are you hypersensitive or allergic to:

Any drugs? Please name:

Any food? Please name:

Any environmental things? Please name:

Do you use smoke, vape, or use cannabis?

Yes

Past

If yes, or in the past, how many years?

If yes, or in the past, how many packs, cigarettes, cartridges, etc., per day or week?

Are you currently receiving healthcare for any reason?

Yes

If yes, from whom and where are they located?

For what reason(s)?

What are the three, most important health problems or goals that you would like to address at your first visit?

Do you have a diagnosed illness or disease that should be known as a part of your health history?

PLEASE LIST ALL VITAMINS, HERBS, SUPPLEMENTS, PRESCRIPTION MEDICATIONS, AND OVER
THE COUNTER MEDICATIONS YOU ARE TAKING ON A REGULAR BASIS.
Please include ingredients, milligram amounts, how often taken, etc.
PLEASE BRING IN THE BOTTLES OR LABELS or EMAIL US clear photos of the front and back labels of EACH bottle so I can see the details.

*** YOU MAY USE ANOTHER SHEET OF PAPER, IF NECESSARY

VITAMINS, HERBS, SUPPLEMENTS, PRESCRIPTION MEDICATIONS,

GENERAL

Weight today lbs. (or kilos)

Weight one year ago? lbs. (or kilos)

Height

Maximum weight lbs. (or kilos)

Desired weight lbs. (or kilos)

when was this last checked

CANCER PATIENTS, ONLY

What surgeries have you had for your condition and when?

Have you had or are you now receiving any chemotherapy (oral or IV) or immunotherapy treatment? If yes, which drugs, how many cycles, when was your last treatment, etc.?

Have you had any radiation treatments of any type? Which body part(s)? Approximately how many treatments and when?

FOR ALL OTHER CONDITIONS

What surgeries have you had and when?

When have you been hospitalized and what was the purpose?

SOCIAL HISTORY

Are you:

DO YOU Live:

Occupation/ profession

Hours per week

Are you retired?

Employer

In a typical week, how many times do you talk in person or on the telephone with family, friends, or neighbors?

In a typical week, how often do you get together, in person, with friends, relatives, or neighbors?

Do you belong to any social organizations, groups, churches, spiritual groups or do you volunteer?

Main interests and hobbies:

SCREENINGS:

Date of last Physical Exam?

Colonoscopy?

Labs?

Males: Prostate Exam?

Females: Last PAP smear or pelvic exam?

Females: Last mammogram?

FAMILY HISTORY

Please note if any of these diseases/problems are (or were) applicable to your parents, grandparents, uncles,
aunts, or siblings.
Please note for whom it was a problem.

Cancer & Type

Diabetes

Heart Disease

High Blood Pressure

Strokes

Mental Illness

Are your parents, grandparents, siblings, and children all still living?

If not, please note their cause of death and at what age(s), if known?

Typical Food Intake- Examples, as we know it varies…

Breakfast:

Lunch:

Dinner:

Snacks:

Beverages:

EXERCISE

Do you exercise?

Yes

Past

If yes, what type of exercise

How often do you exercise?

How many minutes per workout?

For the following sections, please use this KEY:

Y = a condition you have now N = a condition you have never had P = had in the past

Do you average 7-8 hours of sleep?

Do you sleep well?

Do you awaken rested?

Do you have a supportive relationship?

Do you have a history of any abuse?

Any major traumas?

Do you eat 3 or more meals / day?

Do you go on diets, often?

Do you drink any coffee?

Do you eat out, often (4x/week or more)?

Do you drink black tea?

Do you add salt to your food?

Do you enjoy your work?

Take vacations?

Spend time outside?

Do you watch TV, YouTube, stream shows?

For TV, YouTube, Streaming how many hrs./day?

Do you read, regularly?

How many hours/day?

Do you use alcoholic beverages?

How much, how often?

Have you been treated for any addictions?

Do you drink cola or other sodas/soft drinks?

How many hrs./day for “Screen time”?

Sexual orientation

Are you, currently, having sexual relations with a partner?

Yes

Are there any sexual difficulties?

Birth control used? If yes, which type(s)?

Do you have children? Please list names, sex, and ages.

Do you travel often for work?

Yes

Do you travel to any undeveloped countries? List:

Are you exposed to any chemicals or occupational hazards as a part of your day or work?

Do you have any pets? If so, please list type

HEAD

Do you have chronic headaches, migraines, head injury history, TMJ problems, etc.? PLEASE LIST

EYES

Do you have impaired vision, visual disturbances, eye pain, “dry eye syndrome”, excessive tearing, glaucoma, cataracts, macular degeneration, etc.? PLEASE LIST

EARS

Do you have impaired heating, ringing in your ears (tinnitus), ear pain, etc.? PLEASE LIST

NOSE AND SINUSES

Do you suffer from frequent colds or sinus infections, nose bleeds, loss of smell, etc.? PLEASE LIST

MOUTH AND THROAT

Do you have any issues with frequent sore throat/mouth/lips or tongue; hoarseness, teeth grinding, gum problems, dental problems, etc.? PLEASE LIST

SEASONAL ALLERGIES

Do you have any seasonal allergy symptoms? What are your symptoms? What time of year? PLEASE LIST

RESPIRATORY

Do you have any issues with a chronic cough, asthma, wheezing, shortness of breath? PLEASE LIST

Have you had pneumonia or bronchitis, recently?

Have you been told you have COPD?

Do you have a Tuberculosis history?

CARDIOVASCULAR

Do you have a history of high cholesterol, heart attacks, blood clots, high blood pressure, chest pain, valvular problems, arrythmias, palpitations, etc.? PLEASE LIST

BLOOD/PERIPHERAL VASCULAR

Do you have excessive bruising, easy bleeding, circulation problems, chronic anemia, etc.? PLEASE LIST

GASTROINTESTINAL

Do you have any trouble with swallowing, nausea, vomiting, heartburn/acid reflux/GERD; a gastric ulcer history, excessive bloating, burping, flatulence; hemorrhoids, liver disease, etc.? PLEASE LIST

HOW OFTEN DO YOU HAVE A BOWEL MOVEMENT?

Are your stools well formed, hard, painful, loose, diarrhea or difficult to pass? Please describe.

Do you have a lot of straining or pass any blood or mucus with bowel movements?

BONES/BACK/NECK/JOINTS/MUSCLES

Do you have problems with joint pain, stiffness, arthritis, muscle cramps, muscle spasms, back pain, neck pain, etc.? PLEASE LIST

Have you had a bone density scan?

If yes, when was the last one?

Do you have osteopenia or osteoporosis?

NEUROLOGY

Do you have a history of seizures, loss of consciousness, memory issues, muscle weakness, numbness or tingling; paralysis, vertigo/dizziness, neurological disorders? PLEASE LIST

SKIN

Do you have issues with rashes, hives, eczema, acne, recurrent boils, unusual skin lesions/moles; hair loss? PLEASE LIST

ENDOCRINE

Do you have hyper or hypothyroidism, diabetes Type I or II, pituitary problems, etc.? PLEASE LIST

IMMUNE

Do you have a history of frequent infections, negative reactions to vaccinations, slow wound healing, etc.?

URINARY/KIDNEY

Do you have pain with urination, inability to hold your urine, urinary frequency, frequent infections, a history of kidney stones; kidney disease, etc.? PLEASE LIST

MALE REPRODUCTIVE SYSTEM

Do you have a history of hernias, testicular problems, prostates problems, sexually transmitted infections, ED?

FEMALE REPRODUCTIVE SYSTEM

Age of first period?

Age/date of last period?

Day 1 of period to Day 1 of next period is = Days

Are periods/cycles regular?

Yes

Duration of days for period bleeding?

Painful periods?

Yes

Heavy or excessive flow?

Yes

PMS symptoms?

Yes

If yes, what are your symptoms?

Endometriosis history?

Yes

Ovarian cyst history?

Yes

Fibroid tumors

Yes

Number of pregnancies

Number of live births

Number of miscarriages

Abnormal PAP history?

Yes

Cervical dysplasia?

Yes

Sexually transmitted infections?

Yes

Please list

Gynecological surgeries/procedures?

Menopausal symptoms?

Yes

Please list

Do you perform breast self-exams?

Yes

Breast pain/tenderness/nipple discharge?

Yes

MENTAL / EMOTIONAL / PSYCHOLOGICAL

Do you have a diagnosed, mental health disorder?

Do you have mood swings, depression, anxiety, get easily stressed?

Have you ever considered or attempted suicide?

When?

FINANCES

Please choose your difficulty for paying for basic expenses like food, housing, medical care, and utilities.

Very hard

Hard

Somewhat hard

Not very hard

VIOLENCE

Within the last year, have you been humiliated or abused by your partner or ex-partner?

Within the last year, have you been afraid of your partner or ex-partner?

Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?

Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?

How do your current health conditions affect you?

What do you feel needs to happen for you to feel better?

What do you enjoy most in your life?

How much change are you willing to make, currently, to improve your health?

Is there anything else you would like to add?

Welcome!
We are glad to serve you!

227 West Janss Road Suite 135 Thousand Oaks, CA

LATEST NEWS

The science of OMICm Age with Harvard and TruDiagnostic researchers.

Low Cholesterol: Is There a Neurologic Link?

CONTACTS

Adult Health History Form Kristin Stiles Green, NMD, FABNO

Neuron Medical Corporation

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