Health History

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Health History

Please Fill Out Form as Best You Can and Submit it by Clicking the Button Below

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Name *

First

Last

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Address *

Line 1

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City

State

Zip Code

Country

Occupation *

Phone Number *

Height *

Weight *

Marital Status *

Number of Children *

Today's Date *

Email *

Date of Birth *

Gender *

Check Box *

Debilitating Fatigue Depression Disinterest in Sex Disinterest in eating

Check Box *

Shortness of Breath Panic Attacks Headaches Dizziness

Check Box *

Insomnia Nausea Vomiting Diahrrhea

Check Box *

Chronic Pain/Inflammation Bleeding Discharge Itching/Rash

Illnesses, Symptoms

Check all That Apply *

Arthritis Allergies/Hay ever Asthma Alcoholism Alzheimer's Disease Autoimmune Disease High Blood Pressure Bronchitis Cancer Chronic Fatigue Syndrome Carpal Tunnel Syndrome Cholesterol (elevated) Circulatory Issues Colitis Dental Issues Depression Diabetes Diverticular Disease Drug Addiction Eating Disorder Epilepsy Emphysema Eyes, Ears, Nose, Throat Issues Environmental Sensitivities Food Intolerance Gastroesophageal Reflux (GERD) Genetic Disorder Glaucoma Gout Heart Disease Infection (chronic)

Health Habits *

Tobacco Cigarettes Cigars Wine Liquor Beer Coffee Tea Soda Water Other

Date of Last Physical Exam *

Reason for Consultation *

List of Surgerys *

Check all That Apply *

Inflammatory Bowel Disease Irritable Bowel Syndrome Kidney or Bladder Disease Learning Disabilities Liver or Gallbladder Disease Mental Illness Migraine Headaches Neurological Issues Sinus Issues Stroke Thyroid Issues Obesity Osteoporosis Pneumonia Sexually Transmitted Disease Seasonal Affective Disorder Skin Problems Tuberculosis Ulcer Urinary Tract Infection Varicose Veins Other

Exercise Per Week *

Exercise (Length) *

Hours of sleep per night *

Time of Day You Feel the Most Energy *

Current Level of Stress *

Time of Day You Feel the Worst *

List of Current Health Issues *

Top Causes of Stress *

Would You Like To; *

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 Focused Be More Organized Think More Clearly Improve Memory Not Be Dependent on Over - the - Counter Meds Be Free of Pain Sleep Better Have Agreeable Breath Have Stronger Teeth Have Agreeable Body Odor Get Less Colds Decrease Allergies

WOMEN

Check all That Apply *

Menstrual Irregularities Endometriosis Infertility Fibrocystic Breasts Fibroids/Ovarian Cysts PMS Breast Cancer Pelvic Inflammatory Disease Vaginal Infections Decreased Sex Drive STD C - Section Surgical Menopause Menopause Other

Age of First Period *

Date of Last Gynecoloogical Exam *

Form of Birth Control *

Date of Last Menstrual Cycle *

Interval of Time Between Cycles *

Length of Cycle *

Do You Experience any of these Symptoms Everyday *

MEN

Men Only *

BPH Prostate (cancer) Decreased Sex drive Infertility Erectile Dysfunction STD Other

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