Health History Questionnaire

General Information

First Name

Last Name

Date of Birth

Age

Height

Sex

Occupation

Number of Children

Marital Status

Are you recovering from the flu?

Yes No

Are you pregnant?

Yes No

Date of last physical exam

Practitioner Name

Practitioner Number

Lab Procedures Performed

Outcome

What is the reason for your visit?

What methods, modalities and therapies have you tried?

List any current health problems for which you are being treated

Current Medications

List any medications you are currently taking in the fields below (prescription or over-the-counter)

MedicationsL1

MedicationsR1

MedicationsL2

MedicationsR2

MedicationsL3

MedicationsR3

MedicationsL4

MedicationsR4

MedicationsL5

MedicationsR5

MedicationsL6

MedicationsR6

Major Hospitalizations, Surgeries, Illnesses, or Injuries

Please list all procedures, complications (if any), and dates.

Approx. Date

Surgery/Illness/Injury

Outcome

MajorEvent_Date_1

MajorEvent_Description_1

MajorEvent_Outcome_1

MajorEvent_Date_2

MajorEvent_Description_2

MajorEvent_Outcome_2

MajorEvent_Date_3

MajorEvent_Description_3

MajorEvent_Outcome_3

MajorEvent_Date_4

MajorEvent_Description_4

MajorEvent_Outcome_4

MajorEvent_Date_5

MajorEvent_Description_5

MajorEvent_Outcome_5

MajorEvent_Date_6

MajorEvent_Description_6

MajorEvent_Outcome_6

Chronic/Recurring Symptoms

What is the level of stress you are experiencing, on a scale of 1-10?

Identify the major causes of stress

Do you experience any of these general symptoms EVERY DAY? (Select all that apply)

Debilitating fatigue Depression Disinterest in sex Disinterest in eating Shortness of breath Panic attacks Headaches Dizziness Insomnia Nausea Vomiting Diarrhea Constipation Fecal incontinence Urinary incontinence Low grade fever Bleeding Inflammation Discharge Itching/rash Chronic pain

Medical History

Is your job associated with any harmful chemicals?

Please select the conditions that you have been diagnosed with (either now or in the past)

Arthritis Allergies/hay fever Asthma Alcoholism Alzheimer’s disease Autoimmune disease Blood pressure problems Bronchitis Cancer Chronic fatigue syndrome Carpal tunnel syndrome Cholesterol (elevated) Circulatory problems Colitis Dental problems Depression Diabetes Diverticular disease Drug addiction Eating disorder Epilepsy Emphysema Environmental sensitivities Eyes/ears/nose/throat problems Fibromyalgia Food intolerance GERD disease Genetic disorder Glaucoma Gout Heart disease Infection (chronic) Inflammatory bowel disease Irritable bowel syndrome Kidney/bladder disease Learning disabilities Liver/gallbladder disease (stones) Mental illness Migraine headaches Sinus problems Stroke Thyroid trouble Obesity Osteoporosis Pneumonia STD Seasonal affective disorder Skin problems Tuberculosis Ulcer Urinary tract infection Varicose veins Neurological problems (Parkinson’s, paralysis, etc.)

Other Conditions - Checkbox

Other:

MedHist Other Conditions - Text input

Male-specific
Select all that apply

Benign prostatic hyperplasia (BPH) Decreased sex drive Sexually transmitted disease Prostate cancer Infertility

Female-specific
Select all that apply

Breast cancer Endometriosis Infertility Fibrocystic breasts Fibroids/ovarian cysts Menstrual irregularities Premenstrual syndrome (PMS) Pelvic inflammatory disease Mammogram PAP C-section Menopause Surgical menopause Vaginal infections Decreased sex drive Sexually transmitted disease

Age of First Period

Date of Last Menstrual Cycle

Length of Cycle (days)

Interval Between Cycles (days)

Last Gynecological Exam

Any recent changes in normal menstrual flow? (e.g. heavier, large clots, scanty)

Form of Birth Control

Number of Children

Number of Pregnancies

Family Health History (Parents and Siblings)

Select any diseases and health conditions in your family

Arthritis Asthma Alcoholism Alzheimer’s disease Blood pressure problems Cancer Depression Diabetes Drug addiction Eating disorder Genetic disorder Glaucoma Heart disease Infertility Learning disabilities Mental illness Migraine headaches Obesity Osteoporosis Stroke Suicide Neurological disorders (Parkinson’s, paralysis, etc.)

Other Conditions - Checkbox

Other:

FamHist Other Conditions - Text input

Lifestyle Habits

Tobacco

Cigarettes per Day

Cigars per Day

Alcohol

Alcohol (Low-Moderate) Alcohol (Heavy)

Wine Glasses per Week

Liquor Ounces per Week

Beer Glasses per Week

Wine Glasses per Day

Liquor Ounces per Day

Beer Glasses per Day

Caffeine

Coffee: 6oz Cups per Day

Tea: 6oz Cups per Day

Sodas w/ Caffeine per Day

Other Sources

Water

Glasses per Day

Exercise

Frequency

5-7 days per week 3-4 days per week 1-2 days per week Less than once per week

Exercise Activities

Walking Running, jogging, jump rope Weight lifting Swimming Boxing Yoga

Activities Other Checkbox

Other:

Exercises Other - Text input

Nutrition & Diet

Diet

Vegetarian Vegan Salt restriction Fat restriction Starch/carbohydrate restriction The Zone Diet Total calorie restriction Mixed food diet (animal & vegetable sources)

Food Restrictions (foods you have to avoid)

Dairy Wheat Eggs Soy Corn All gluten

Other Restrictions Checkbox

Other:

Other Restrictions - TextInput

Food Frequency

Fruit (e.g. citrus, melon)

Dark green or deep yelow/orange vegetables

Grains (unprocessed)

Beans, peas, legumes

Dairy, eggs

Meat, poultry, fish

Eating Habits

Skip breakfast One meal/day Two meals/day Three meals/day Graze (small frequent meals) Eat constantly Food rotation Add salt to food Generaly, eat on the run

Current Supplements

Multivitamin/mineral Vitamin C Vitamin E EPA/DHA Evening Primrose/GLA Calcium Magnesium Zinc Minerals Digestive enzymes Amino acids Bach flowers CoQ10 Liquid meals Protein shakes Herbs - teas Herbs - extracts Chinese herbs Ayurvedic herbs Homeopathy Friendly flora (acidophilus) Antioxidants (e.g., lutein, resveratrol, etc.) Superfoods (e.g., bee pollen, phytonutrient blends)

Supplements Other - Checkbox

Other:

Supplements Other - TextInput

Pain Points

Would you like to: (select all that apply)

Have more energy Be stronger Have more endurance Increase your sex drive Be thinner Be more muscular Improve your complexion Have stronger nails Have healthier hair Be less moody Be less depressed Be less indecisive Feel more motivated Be more organized Think more clearly/be focused Improve memory Do better on tests in schoo Be free of pain Sleep better Have agreeable breath Have agreeable BO Have stronger teeth Get fewer colds and flu Get rid of allergies Stop using laxatives/stool softeners Not be dependent on over-the-counter medications like aspirin, ibuprofen, antihistamines, sleeping aids, etc. Reduce your risk of inherited disease tendencies (e.g., cancer, heart disease, etc.)

Indicate areas where you feel pain, swelling, or discomfort, or areas of your skin that have changed color or texture (e.g, moles, rashes, etc.). Describe what you observe in your own words: