HEALTH HISTORY FORM
First Name
*
Last Name
*
Street
*
City
*
State
*
Zip Code
*
E-mail
*
Telephone
*
Is your Father living
*
yes
no
Is your Mother living
*
yes
no
Number of brothers
*
Select ->
1
2
3
4
5
6
more
Number of sisters
*
Select ->
1
2
3
4
5
6
more
Any surgeries
*
yes
no
If yes, what for
Any serious disease(s)
*
yes
no
If yes, please list
Are you on any medication
*
yes
no
If yes, please list
Do you have any allergies
*
yes
no
If yes, please list
Ladies, do you have burning when urinating, trouble starting or stopping stream, blood in urine, frequency, pelvic pain, pain on intercourse, urinary infections, etc
yes
no
If yes, please describe
Ladies, do you have menstrual irregularities, pelvic infections, painful menstrual periods, etc.
yes
no
If yes, please describe
When was your last menstrual period
Are you taking hormones or birth control pills
yes
no
Number of pregnancies
0
1
2
3
4
5
6
more
Number of children born
0
1
2
3
4
5
6
more
Any problems or complications with childbirth
yes
no
If yes, please describe in detail
Have you had a hysterectomy or tubal ligation
yes
no
If yes, at what age
What was the medical reason for the hysterectomy/tubal ligation
Men, any problems with prostate, elevated PSA, do you get up a lot at night to urinate
yes
no
If yes, please describe in detail
Do you or have you experienced chest tightness, shortness of breath, racing heart, high blood pressure, coldness in extremities, swelling in fingers or feet, numbness in fingers or feet
yes
no
Do you or have you experienced headaches, dizziness, blurred vison, double vision, black out spells, or memory loss
yes
no
Do you or have you experienced joint pain, motion restriction, joint swelling, weakness, muscle cramps or pain
yes
no
Do you or have you had rashes, breaking out, discoloration, itchng, sores, ulcers, calluses
yes
no
Do you or have you had coughs, colds, respiratory infections, sinus infections and/or congestion, asthma, emphysema
yes
no
Do you or have you experienced gum disease, tooth decay, silver fillings, root canals and/or implants
yes
no
How much water do you drink each day
1-8oz glass
2-8oz glasses
3-8oz glasses
4-8oz glasses
5-8oz glasses
6-8oz glasses
more
What type of water do you drink
city
tap
well
spring
purified
reverse osmosis
filtered
steam distilled
How much soda pop do you drink daily
1
2
3
5
6
more
How many cups of coffee do you drink daily
1
2
3
4
5
6
more
How many cups of tea do you drink daily
0
1
2
3
4
5
6
more
If you do drink tea, what kind of tea
How many glasses of store bought milk do you drink daily (homogenized/pasteurized)
0
1
2
3
4
5
6
more
Do you have a sweet tooth
yes
no
Do you feed your sweet tooth often
yes
no
Do you eat fast foods often
yes
no
Do you chew your foods well
yes
no
How often do you take MORE than 20 minutes to eat
never
rarely
sometimes
frequenty
all the time
How many meals do you eat daily
1
2
3
4
more
How often do you eat red meat
never
rarely
sometimes
frequently
at almost every meal
What percentage of your food would be raw food (fruits, vegetables, nuts, whole grains, raw seeds)
How would you rate your diet
Good
Average
Poor
Exercise, how often
5 days per week
3 days per week
seldom
never
Number of bowel movements per day
3 or more
twice
once
les than daily
How is your weight
optimum
25 lbs over
50 lgbs over
100 lbs over
other
If more than 100 lbs. overweight, how much more?
Best time to reach you by phone
(
*
Required Field )
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