Please write in your top 3 health complaints/ concerns inorder of importance to you. Check the items that make it better or worse and mark the severity of the condition on the scale from 1-5 (0=No symptoms, 5=worst ever)
How warm/cold do you feel (not in degrees); relative to other people do you wear more or less clothing, etc.
Your overall body moisture (hair, skin, mouth, etc.)
We greatly appreciate your time in filling out your healt history. . .it is the first step in enabling us to give you the most appropriate and high quality care that you expect from our clinic.