Street Address *
Apt #
City *
State *
Date of Birth *
Zip Code *
Height
Weight
Email *
EMERGENCY CONTACT:
Name
Relationship
Single Line Text
Phone #
HEALTH HISTORY
On a scale of ‘1 to 10’, please rate the intensity of your chief complaint (0 – no discomfort, 10 = extreme discomfort)
How are your health problems interfering with the following areas of your life?
Work
Family
Hobbies
Life
How did the previous methods work for you?
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
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 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
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.
