Kidney stone Patient Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *SexMaleFemaleMarital statusWhat are your symptoms?How long has it been since you were first diagnosed?< 1 year1-3 Years3-5 Years5-10 Years> 10 yearsPlease select the option to indicate the severity of your pain.How was this diagnosed?UltrasoundX-RaysCT scanHave you been told that you have diabetes, high blood, kidney stones before?Have you ever had any of the following (Check if yes):Pain and discomfort in kidney area?Hospitalization due to sudden pain?You had nauseated feeling?Blood in the urine?Pain or burning during urination?Difficulty in emptying your bladder?Any fever or chills?Radiation to the abdomen or pelvis?Chemotherapy for cancer?Family history of kidney disease?Blood in the urine?Foamy urine?If you answered yes to any of the above, please enter more details here:Do you use regularly pain or anti-inflammatory medicines or NSAIDS (i.e. Aleve, naproxen, ibuprofen, Motrin)YesNoIf answered yes in the previous question, how often?DailyWeekly3 times per weekMonthlyDo you use herbal or Calcium supplements?YesNoIf yes, list them here pleaseDo you have high blood pressure or take medicine for high blood pressure? Y / N (If no, skip to next section).How long ago were you first diagnosed?1 year1-3 years3-5 years5-10 years> 10 yearsDo you check your blood pressure at home?YesNoIf yes, how often?DailyWeeklySeveral times a weekMonthlyHow often is your blood pressure greater then 140/90?Most of the TimeOccasionallyNeverDo you add salt to your food?NoOccasionallyOftenWith each mealDo you eat canned or processed food?NoOccasionallyFew times a weekEvery DayIf you exercise, how often?Daily3 Times per weekOnce a weekOnce a monthDo you snore?YesNoIf yes, are you sleepy during the daytime or take frequent naps?YesNoHave you ever been hospitalized for high blood pressure?YesNoHave you had a stroke?YesNoDo you have heart failureYesNoHave you had a heart attack?YesNoHave you had a surgery for arteries supplying the legs?YesNoHave you ever been told you have diabetes or prediabetes? Y / N (If no, skip to next section)YesNoHow long ago were you first diagnosed?1 year1-3 years3-5 years5-10 years> 10 yearsDo you take or have you ever taken pills for diabetes?YesNoDo you take or have you ever taken insulin?YesNoHow well have you blood sugars been controlled? Usually< 100100-150150-200> 200I don't check themDo you have eye disease from diabetes?YesNoHave you had laser treatment for your eyes?YesNoDo you have numb feet?YesNoHave you ever been told you were anemic, had a low blood or hemoglobin count? Y / N (If no, skip to next section).YesNoHow long ago were you first diagnosed?< 1 year1-3 years3-5 years5-10 years> 10 yearsHave you had to take medication to prevent anemia?YesNoHave you had to take medication to prevent anemia?Folate or folic acidIronB12Epogen or AranespNoneDo you have any black stools?YesNoDo you have any bright red blood in your stool?YesNoDo you have any blood in your urine?YesNoIf female, do you still menstruate?YesNoDo you have a family history of anemia?YesNoHave you ever been diagnosed with the following: (copy)LymphomaLeukemiaVomiting bloodStomach ulcersRecurrent nosebleedsAny other cancersHave you ever been told you had osteoporosis, osteopenia, brittle, thin or weak bones? Y / N (If no, skip to the next section)YesNoWhen were you told you had osteoporosis, osteopenia, brittle, thin or weak bones?< 1 year1-3 years3-5 years5-10 years> 10 yearsHow was it diagnosed:Bone ScanBroken BonesDo you take any medication or Supplements for your bones?YesNoIf yes, what type:CalciumVitamin DCalcium and Vitamin D ContributionBisphosphatesOther specifyIf you answered yes to any of the above please enter any details you feel pertinent here.Do you have any specific concerns regarding your kidney stones that you would like to have addressed today?NameSubmit