Street Address * Apt # City * State * Date of Birth * Zip Code * Height Weight Email * Can we leave a message, if you’re not available? EMERGENCY CONTACT: Name Relationship Single Line Text Phone # How did you hear about us? HEALTH HISTORY On a scale of ‘1 to 10’, please rate the intensity of your chief complaint (0 – no discomfort, 10 = extreme discomfort) On AVERAGE your complaint is At WORST your complaint is What Aggravates or Alleviates your Chief Complaints? How are your health problems interfering with the following areas of your life? Work Family Hobbies Life How have you taken care of your health in the past? How did the previous methods work for you? If you were to sit down and discuss your life 3 years from now and look back at today, what would have to happen for you to be happy with your progress?
(please take your time and don’t sell yourself short)
What potential barriers do you foresee that would prevent you from achieving your Health goals? Rate on a scale of 1-10 (1 being lowest, 10 being highest) How important is it for you to resolve your health concerns? 1 2 3 4 5 6 7 8 9 10 Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals? 1 2 3 4 5 6 7 8 9 10 If yes, how far along? Explain Do your work activities mostly involve: What is your daily intake of the following: Comments Imaging & Tests X-ray (s) MRI (s) CT (CAT Scan (s) Ultrasound (s) Cholesterol Blood Sugar Mammogram PAP Smear Blood Tests (Which) Nerve Conduction Please check to indicate if you have ever had any of the following: Please list ALL health care providers (family, physicians, surgeons, specialists, chiropractors, etc.) currently treating you: List ALL disorders you are CURRENTLY being treated for (include the dates of when you were diagnosed) List ALL disorders you have had, or have been diagnosed with (include the dates of when you were diagnosed): List ALL types of Surgeries you have had in the past (includes dates): List ALL Accidents and/or hospitalizations you have had in the past (include dates): List ALL Allergies (Food, Medications, Pollen, etc.): List ALL Medicines (prescriptions & over-the-counter) you are CURRENTLY taking (include duration of use & Dosage): List ALL Nutritional supplements, Herbs, or Vitamins, you are currently taking: List all Medical conditions of your immediate family: MOTHER Age if living If deceased, cause of death Cancer (s) Diabetes Heart Disease Stroke Autoimmune Disorders Mental Illness Other FATHER Age if living If deceased, cause of death Cancer (s) Diabetes Heart Disease Stroke Autoimmune Disorders Mental Illness Other BROTHERS Age if living If deceased, cause of death Cancer (s) Diabetes Heart Disease Stroke Autoimmune Disorders Mental Illness Other SISTERS Age if living If deceased, cause of death Cancer (s) Diabetes Heart Disease Stroke Autoimmune Disorders Mental Illness Other We find that when all of your healthcare providers are up to date with your treatment progress, it makes it easier for all of us to better help you improve your health. Is it okay if we contact the above healthcare providers to update them on the treatments you are receiving here? IMPORTANT: Complete these documents as thoroughly as possible, please be honest with yourself. Some of the questions that follow may seem unrelated to your condition, BUT they may play a major role in diagnosis and treatment. All information is strictly confidential. ORAL & UPPER RESPIRATORY HEALTH