Balanced health NP
PA
General
Smoking
Yes, currently
No
Clear
Yes, in the past
Blood Type
A-
A+
AB-
AB+
B-
B+
O-
O+
Not Known
General Section Notes
Food Allergies
Egg
Fish
Milk
Nuts
Peanuts
Shellfish
Soy
Wheat
Allergen
Food Allergy Notes
Drug/Herb Allergy Details
No Known Drug Allergies
Drug/Herb
Herb/Drug Allergy Notes(One entry per line)
Ineffective Meds
Meds
Ineffective Meds Notes
Patient Medical History
1. Anemia
Present
Past
Rarely
Never
2. Arthritis
Present
Past
Rarely
Never
3. Asthma
Present
Past
Rarely
Never
4. Alcoholism
Present
Past
Rarely
Never
5. Bleeding
Present
Past
Rarely
Never
6. Cancer
Present
Past
Rarely
Never
7. Colitis
Present
Past
Rarely
Never
8. Heart Murmur
Present
Past
Rarely
Never
9. Blood Pressure
Present
Past
Rarely
Never
10. Injury
Present
Past
Rarely
Never
11. Kidney disease
Present
Past
Rarely
Never
12. Jaundice
Present
Past
Rarely
Never
13. Overweight
Present
Past
Rarely
Never
14. Ulcers
Present
Past
Rarely
Never
15. Diabetes
Present
Past
Rarely
Never
16. Hypoglycemia
Present
Past
Rarely
Never
17. Allergies
Present
Past
Rarely
Never
18. Candida (yeast)
Present
Past
Rarely
Never
19. Emphysema
Present
Past
Rarely
Never
20. Drug/Alcohol
Present
Past
Rarely
Never
21. Eczema/Psoriasis
Present
Past
Rarely
Never
22. Headache/migraines
Present
Past
Rarely
Never
23. Pneumonia
Present
Past
Rarely
Never
24. Rheumatism
Present
Past
Rarely
Never
25. Hyperthyroid
Present
Past
Rarely
Never
26. Hypothyroid
Present
Past
Rarely
Never
27. Tuberculosis
Present
Past
Rarely
Never
28. Venereal Disease
Present
Past
Rarely
Never
29. Hemorrhoids
Present
Past
Rarely
Never
30. Abdominal pain
Present
Past
Rarely
Never
Diet and other Restrictions
Vegetarian
Vegan
Organic
Egg Restriction
Salt Restriction
Fat Restriction
Starch/Carbohydrate Restriction
Soy Restriction
Calorie Restriction
Dairy Restriction
Wheat Restriction
Gluten Restriction
Other Restrictions
Immunizations
Polio
Tetanus shot
Haemophilus influenzae
Pneumococcal infections
Measles/Mumps/Rubella
Pertussis
Human papillomavirus
Rotavirus
Diphtheria
Chickenpox
Influenza
Shingles
Hepatitis A
Hepatitis B
Meningococcal meningitis
Covid
Select
Moderna
AstraZeneca
J&J
Pfizer-BioNTech
Novavax
Other
Add Immunization Entry
Print Immunization Min
Print Immunizations
Xrays and Special Studies
Info
Surgical History
Info
Antibiotic History
Info
Accidents/Injuries/Transfusions
Type, Date, Details
Hospitalization
Diagnosis Type, Date, Treatment
Screening Tests
Vision, Hep-A/B/C, Mammogram, Colorectal, Prostate
Dental History
Mercury fillings, Root canal(s),Tooth abscess(es)
Recent Lab Work
Test, Date, Result
Personal and Family History Conditions
Please select if you or your family (Mother, Father, Sibling, Maternal grandmother, Maternal grandfather, Paternal grandmother, Paternal grandfather) have any history with the following conditions.
If deceased, relevant info:
Mother
Father
Sibling
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
Personal and Family History Notes & Conditions Not Listed Above
Reproductive Section
Sexually Active
Yes, currently
No
Clear
Yes, in the past
Sexual Orientation
Hetero
Gay
Lesbian
Bi
Other
Clear
Periods started at age
Typical period length
Date of Last Menses
Perform Monthly breast self-exams?
Yes
No
Clear
Menopause
Please indicate age, peri-menopausal & current symptoms & treatment
Last Pap Smear
Please indicate the date and if it was normal, abnormal or any resulting action
Child Births
Please indicate year; vaginal/c-section; gender; complications
Miscarriages/terminations
Please indicate year; vaginal/c-section; gender; complications
Hormones used
Please indicate if current or past, reason for stopping, side effects, dosages
Mammography results
Please indicate the dates, results
Abnormal vaginal bleeding
Please indicate the dates, quantity/quality, treatment if applicable
Notes
Reproductive Section Notes
Patient Family History
Condition
Relation
Family History Notes
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Personal Note
Hey, I have been using OptiMantra in our practice and would like to invite you to try it for your practice. As part of this referral, you will receive a 10% discount on the subscription fee. You can visit https://www.optimantra.com, call 866-868-5070 or just Reply All to this email with a preferred date and time for a demo. Thanks!
You (Referrer) will get a $150 gift card per sign-up [Effective 12/15/2021]
