d1ajls23knb7pl.cloudfront.net · Do you have hearing loss with your vertigo? Do you have any ringing in your ear with your vertigo? Is there any correlation with timing of your symptoms

LAKEVIEW INTEGRATIVE MEDICINE

PATIENT MEDICAL HISTORY FORM

- BRIEF LIST OF CHIEF COMPLAINTS IN ORDER OF THEIR IMPORTANCE TO YOU.

- BRIEF LIST ALL DIAGNOSIS GIVEN TO YOU CHRONOLOGICALLY, AND YOUR PERSONAL OPINION

ABOUT THE DIAGNOSIS.

- LIST YOUR OPINION ON WHAT YOU THINK HAS HAPPENED TO YOUR HEALTH.

- LIST ALL HEALTH CARE PROVIDERS YOU HAVE CONSULTED, THEIR OPINIONS AND TREATMENT.

- LIST ANY TREATMENT, MEDICATION OR SUPPLEMENTS THAT HAVE IMPROVED YOUR HEALTH.

- LIST CHRONOLOGICALLY ANY MEDICATION YOU HAVE TAKEN IN THE PAST.

- LIST CHRONOLOGICALLY ANY SUGERIES YOU HAVE HAD.

- LIST CHRONOLOGICALLY ANY SIGNIFICANT LABORATORY AND IMAGING RESULTS.

- LIST CHRONOLOGICALLY ANY EXPOSURE TO ENVIRONMENTAL, INDUSTRIAL OR TOXIC

COMPOUNDS.

- LIST ANY HISTORY OF INFECTIONS (EXCLUDE COMMON COLD).