Health History Form
Long 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
Most you have weighted as an adult
Include year
Least you have weighted as an adult
Include year
Occupation
Highest level of education
Marital status
Level of stress you experience (1 - 10)
What are your top three health concerns?
How long have you had these concerns?
Are you willing to make lifestyle changes to address these concerns?
What other health conditions have you had in the past?
Include year
Please describe your parents' current health or cause of death.
Please describe siblings and children's health.
Check conditions which have occurred in your blood relatives
Diabetes
Cancer
Heart disease
Stroke
High blood pressure
Depression/anxiety
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, including brand and dose.
Include dose and frequency
Upper GI symptoms
Sometimes nauseated in evenings
Dry mouth
Occasional foul burps
Quickly feel full
Seldom eat breakfast
Indigestion
Frequent mouth sores
Bad morning breath
Bitter taste in morning
Strong, demanding hunger
Frequent poor appetite
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
Tongue often coated
Liver
Seasonal allergies or asthma
Crave sweets
Trouble digesting fats
Acne on face and buttocks
History of working with solvents
Frequent minor illnesses
Moist, sometimes oil skin
Hives from food or drugs
Crave protein and fats
Frequent use of alcohol (5+ serving/week)
Skin irritations - psoriasis, eczema, dermatitis
Kidneys
Standing quickly causes dizziness
Standing quickly causes roaring ears
Frequent flushing/blushing
Moderately low blood pressure
Moderately high blood pressure
Urine always light colored
Wake up at night to urinate
Frequent water retention
Urine usually dark
Frequent thirst
Craving for salt
Lower Urinary Tract
Frequent urination, small amounts
Occasional post-urination dribble
Demanding need to urinate
Infrequent urination, copious
Frequent bladder infections
Mucous in urine
Dull ache after urination
Reproductive System
Dry skin, cold hands and feet
Oily skin, facial acne
Sweat freely with strong scent
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
Respiratory System
Shortness of breath when standing or walking
Sometimes wake up choking or gasping for breath
Frequent chest colds
Frequent coughing with mucus
Occasional hyperventilation
Rapid, shallow breathing
Cardiovascular System
Fast, light pulse
Slow, strong pulse
Occasional dizziness
Hands cold, clammy or dry
Hands warm and sweaty
Warm-bodied
Cold-bodied
Hypertension not responsive to diuretics
Hypertension, responsive to diuretics
Lymphatic System
Recuperate slowly if ill
Recuperate quickly if ill
Injuries heal slowly
Injuries heal quickly
Eczema, dermatitis
Asthma or seasonal allergies
Arthritis
Skin
Skin eruptions deep
Skin eruptions superficial
Skin on trunk is dry
Oily scalp or hair
Dry scalp or hair
Cracks, fissures on heels, elbows, feet
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?
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