Health History Form

In an effort to provide you with complete care, please complete the questionnaire to the best of your knowledge. The information you provide will assist me in formulating a complete treatment plan for you. All your answers are absolutely confidential. If you have any questions, please do not hesitate to ask. If you need more space, please use the other side of these sheets.

Personal Information

Name *

First

Last *

Last

Address *

Address

City

State/Province

Zip/Postal

Home Phone

Mobile Phone

Email Address *

Date of Birth *

Age *

Marital Status *

Married

Single

Divorced

Widowed

Rather not say

Occupation *

Name of Primary Care Physician *

Primary Care Physician Address *

Primary Care Physician Address

City

State/Province

Zip/Postal

Primary Care Physician Phone Number *

In case of emergency, notify *

Emergency Contact Name

Relationship

Emergency Contact Phone Number *

Main Compliant(s) symptoms, onset, duration, location, etc.)

Health History

Significant Trauma/Injury (physical/emotional)

Surgeries (please include procedure and dates)

Allergies (chemical, environmental, food, drugs, etc.)

Medications (names & dosages)

Vitamins/Supplements/Herbs

How many days per week do you exercise? *

Length of workout/type of activity

Functional History — Has your condition affected your ability to function? *

Yes

Please explain how your condition has affected your functional ability/abilities

Special Equipment (used to function: bracing, feeding equipment, special bed, etc.)

Environment (what is your home like, steps to enter, carpeting, etc.) *

Diet — Meals per day, Snacks, Caffeinated Drinks, Alcohol per week *

What makes your condition better? (Rest, movement, heat, cold, fresh air, eating, crying, etc.) *

What makes your condition worse? (stress, fatigue, hunger, heat, certain foods, damp days etc.)

Personal History (please check any conditions or symptoms you have now)

Arthritis

Liver/Gall Bladder Disease

Stroke

Heart Disease

High/Low Blood Pressure

Hypo/Hyperglycemia

Kidney Disease

Elevated Blood Cholesterol

Cancer

Diabetes

Food Allergies/Intolerance

Diverticulitis/IBS

Ulcers

Seizures

Hepatitis

Raynaud’s Disease

Chronic Fatigue

Anemia

Thyroid Imbalance

Respiratory

Allergies

Alcoholism

Lyme Disease

Chronic Pain Condition

Impotence

Gastritis/Pancreatitis

Asthma

Infertility

Emphysema

OtherOther

General Conditions

Poor Appetite

Poor Sleeping

Fatigue

Fevers

Chills

Night Sweats

Sweats Easily

Tremors

Cravings

Localized Weakness

Poor Balance

Change in appetite

OtherOther

Skin & Hair Conditions (please check any conditions or symptoms you have now)

Rashes

Ulcerations

Hives/Allergic Dermatitis

Itching

Eczema/Psoriasis

Dandruff

Loss of hair

Recent moles

Skin discoloration

Acne

Change in skin/hair texture

Face flushing

Dermatitis

Warts

Fungal Infection

Weak or ridged nails

OtherOther

Head, Eyes, Ears, Nose & Throat (please check any conditions or symptoms you have now)

Dizziness

Difficulty swallowing

Migraines

Glasses

Eye Strain

Eye pain

Poor vision

Night Blindness

Color Blindness

Cataracts

Blurred vision

Earaches

Ringing in ears

Poor hearing

Spots in front of eyes

Sinus problems

Nose bleeds

Recurrent sore throats/colds

Grinding teeth

Facial pain

Sores on lips/tongue

Dental problems

Jaw clicks/locks

Headaches

OtherOther

Cardivascular (please check any conditions or symptoms you have now)

Chest pain or pressure

Irregular heart beat

Palpitations at rest

Fainting

Cold hands/feet

Swelling of hands/feet

Blood clots

Phlebitis

Shortness of breath

Varicose/spider veins

Pressure in chest

High blood pressure

Low blood pressure

Spontaneous sweating

Dizziness

OtherOther

Respiratory (please check any conditions or symptoms you have now)

Cough/Wheezing

Coughing blood

Asthma

Bronchitis

Pneumonia

Pain with deep inhalation

Tight sensation in chest

Difficult inhale/exhale

Difficulty breathing when lying down

Production of phlegm

OtherOther

What color is the phlegm

Gastrointestinal (please check any conditions or symptoms you have now)

Nausea

Vomiting

Diarrhea

Constipation

Gas

Belching

Black stools

Blood in stool

Indigestion

Bad breath

Rectal pain

Hemorrhoids

Bloating/Edema

Chronic laxative use

Loose stools (>2 per day)

Abdominal pain/cramps

Changes in appetite

Acid reflux/GERD

Hernia

Poor appetite

Excessive appetite

Significant thirst

IBS/Crohn’s Disease

OtherOther

Genito-Urinary (please check any conditions or symptoms you have now)

Pain on urination

Frequent urination

Blood in urine

Urgent urination

Unable to hold urine

Kidney stones

Scanty flow

Copious flow

Impotence

Sores on genitals

Urinary tract infection

Burning urination

Premature ejaculation

Decreased libido

Prostatitis

Dribbling after urination

Nocturnal emission

Pain in testicles

Herpes Infections

Excessive libido

Night Urination

Regarding your night urination, what time and how often?

Gynecological/Reproductive (please check any conditions or symptoms you have now)

Difficult/Painful intercourse

Ovarian cysts

Vaginal dryness

Endometriosis

Vaginal sores

Uterine Fibroids

Vaginal discharge

Fibrocystic breast tissue

Infertility

Polycystic Ovarian Disease

Irregular menstruation

PMS

Painful menstruation

OtherOther

Age of first menses

Date of last menses

Date of last PAP/Pelvic

Number of pregnancies

Number of ectopic pregancies

Number of live births

Number of miscarriages

Number of abortions

Do you practice birth control?

Yes

What type of birth control?

How long have you been on birth control?

Musculoskeletal (please check any conditions or symptoms you have now)

Neck pain

Shoulder pain

Hand/wrist pain

Carpal Tunnel

Knee pain

Sprains/Strains

Sciatica

Foot/ankle pain

Hip pain

Muscle pain

Muscle weakness

Tendonitis

Lower back pain

Middle back pain

Upper back pain

Bursitis

Rotator Cuff

Soreness/weakness in lower body (back, knee, hip, ankle, foot)

OtherOther

Neuropsychological (please check any conditions or symptoms you have now)

Seizures

Loss of balance

Vertigo/Dizziness

Areas of numbness

Lack of coordination

Poor memory

Concussion

Depression

Anxiety/Panic attacks

Bad temper/irritable

Easily susceptible to stress

Seasonal Affective Disorder

Nervousness

ADD/ADHD

Manic Depression

OtherOther

Have you ever been treated for emotional problems?

Yes

Have you ever considered or attempted suicide?

Yes

Have you ever been treated for substance abuse?

Yes

Previous Treatment

Put a check by each treatment you have had for the above stated problem(s) in the past. Then check the column that best describes the effect of the treatment.

Treatment

Hot packs/ice

Ultrasound

Massage

TENS/E-stim

Yoga/Tai-chi

Exercises

Traction

Bedrest

Pool Therapy

Injections

Biofeedback

Medications

Acupuncture

Chiropractor

Topical Agents

Did the treatment make things

Better

Worse

No Change

Family Medical History

Please check any condition that applies to your immediate family.

Diabetes

Father

Mother

Sister

Brother

Grandmother

Grandfather

Seizures

Father

Mother

Sister

Brother

Grandmother

Grandfather

Heart Disease

Father

Mother

Sister

Brother

Grandmother

Grandfather

Stroke

Father

Mother

Sister

Brother

Grandmother

Grandfather

High Blood Pressure

Father

Mother

Sister

Brother

Grandmother

Grandfather

Allergies

Father

Mother

Sister

Brother

Grandmother

Grandfather

Cancer

Father

Mother

Sister

Brother

Grandmother

Grandfather

Asthma

Father

Mother

Sister

Brother

Grandmother

Grandfather

Other Condition/Relative

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