Health History Form
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Birthdate
Physician
Reason for last visit to physician
Height and Weight
Occupation
Highest level of education
Level of stress you experience (1 - 10)
Are you pregnant or trying to conceive?
Please list number of pregnancies, number of miscarriages and ages of children.
What is your main reason for scheduling an appointment?
How long have you had this concern?
Have you received a medical diagnosis related to this concern?
Have you received any lab work or imaging studies? If so, please bring to your appointment or send them ahead of time.
Are you willing to make lifestyle changes to address this concern ?
Are you experiencing pain? If so, please rate (1 - 10) and describe location and feeling (i.e. sharp, dull, aching, radiating)
Are you experiencing any functional limitations related to this concern? i.e. difficulty sleeping, walking, working, sitting
What other health conditions do you have or have you had?
Include year
Check conditions which have occurred in your blood relatives
Diabetes
Cancer
Heart disease
Stroke
High blood pressure
Depression/anxiety
Miscarriage
Infertility
Describe a typical breakfast
Describe a typical lunch
Describe a typical dinner
List any foods you crave.
List any food sensitivities.
Do you use, or have you used alcohol, coffee, tobacco, recreational drugs?
If so, include frequency and if current or past.
List exercise, include frequency per week.
List all medications.
List all herbs and supplements.
Include dose and frequency
Please mark all symptoms you are currently experiencing:
Lower GI Symptoms
Constipation with gas
Frequent constipation
Constipation with painful BM
Constipation with hemorrhoids
Mucous in stools
Undigested food in stools
Diarrhea
Loose stools with gas
Difficulty passing stools
Tongue often coated
Lower Urinary Tract
Frequent urination, small amounts
Bladder incontinence with coughing/laughing
Post-urination dribble
Demanding need to urinate
Infrequent urination, copious
Frequent bladder infections
Women
Cycle longer than 28 days
Miss occasional periods
Menses slow to start with cramping
Constipation before menses, followed by loose stools
Class II Pap smear
History of PID, cervicitis
Miscarriages
Unable to take birth control pill due to side effects
Take birth control pill
Cycle less than 28 days
Water retention prior to menses
Menstruation longer than 5 days
PMS - increased hunger
PMS - Breasts tender
PMS - Heart palpitations
Hot flashes
Menopause
Endocrine System
Dry, brittle hair
Loss of head hair
Fatigue
Weight gain
Decreased libido
Lack of hair on legs
Insomnia
Please mark severity of symptoms you experience.
Mild
Moderate
Severe
Awaken at night, can't fall back to sleep
Difficulty falling asleep
Difficulty waking in morning
Bad dreams
Restless sleep
Blurred vision
Eyes often red or inflamed
Face and/or eyes puffy
Bruise easily
Difficulty gaining weight
Difficulty losing weight
Sudden weight loss
Extreme fatigue
Depressed
Highly emotional
Cry easily without apparent cause
Headaches
Heart palpitations when hungry
Heart palpitations after eating
Impaired hearing
Earaches
Ears itchy
Ringing in ears
Numbness or tingling in legs
Numbness or tingling in arms
Muscle cramps
Nails brittle
Low back pain
Frequent nose bleeds
Facial twitches
Sensitive to cold weather
Sensitive to hot weather
Sensitive to humidity
Sexual desire increased
Sexual desire decreased
Frequent nasal congestion
Is there anything else you would like to mention?
Submit
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