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Name _____________________________ Date of Birth ___________ -1-_______________________________________________________________________________________________________

HEALTH HISTORY FORM

Today’s Date ______________________

PERSONAL INFORMATION

First Name ________________________ Last Name ___________________________ Occupation _______________________

Date of Birth ______________________ Height ____________ Weight____________ □ Male □ Female

Marital Status □ Single □ Married □ Separated □ Partner □ Divorced □ Widowed

HOW CAN I HELP YOU?

What is the main reason for your visit today?_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

What treatments (tests/procedures, medicines, therapies, or diets) have you tried to help the condition above?_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

What type of research have you conducted regarding your personal health condition (WebMD, interest groups) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

In what ways do you expect me to help improve your health? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

What are your personal health goals for the next year? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

PERSONAL MEDICAL HISTORY Please mark all medical conditions that you have experienced since childhood to the present date.

Check box under C if a current health issue. Check box under P if a past health issue. Leave blank if it does not apply.

C P C P C P Skin Cardiovascular Lymphatic SystemAcne High blood pressure MononucleosisRosacea High cholesterol/LDL Lymphatic swellingPsoriasis High triglyceridesEczema Low HDL Female OnlyRash/Hives Blood clots Yeast InfectionsDry skin Circulation issues PMS

Stroke Irregular cyclesEyes/Ears/ Varicose veins Breast fibroidsNose & Throat Coronary artery disease Ovarian cystsDry eyes EndometriosisEar infections Gastrointestinal Decreased sex driveAllergies/hay fever Gastric ulcers Length of menstrual cycleSinus infections Gastric reflux-GERD __________________Tonsillitis Irritable bowel syndrome Interval between menstrual

cycles:________________Strep throat Inflammatory bowel dis.Fatty liver/liver dis. # of pregnancies ______

Head/Neurological Hepatitis # of children _________Headaches/migraines Gallstones C-section/EpisiotomySeizures Pancreatitis Menopause ADD/ADHD Diverticulosis VD/STD’sAutism Colon polypsBell’s Palsy Colitis Male Only

Hemorrhoids Prostate enlargementRespiratory/Lungs Constipation/diarrhea Prostate cancerBronchitis Decreased sex drivePneumonia Kidney/Bladder InfertilityAsthma Urinary tract infections VD/STD’sCOPD Kidney stones

Kidney/bladder disease OtherEndocrine Frequent urination Eating disorderHyperthyroid Alcohol/drug abuseHypothyroid MusculoskeletalThyroid nodules Osteoporosis Please describe any health conditions

not listed: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Parathyroid issues OsteopeniaAdrenal issues Joint pain/swellingDiabetes type 1 or 2 Osteoarthritis

Rheumatoid arthritisMental/Emotional GoutAnxietyDepressionMental illness

Name _____________________________ Date of Birth ___________ -2-

FAMILY MEDICAL HISTORY Please list any family medical health conditions that exist

Father _______________________________________ Mother __________________________________________Brother(s) ________________________________________ Sister(s) __________________________________________ ________________________________________________ __________________________________________________________________________________________________ _________________________________________________

SURGERIES Please list any surgeries, hospitalizations, or medical implants you may have had along with the year of occurrence.Date _____________ _____________________________________________________________________________Date _____________ _____________________________________________________________________________ Date _____________ _____________________________________________________________________________

PRESCRIPTION & OVER-THE-COUNTER DRUGSPlease list all prescribed medications and over the counter drugs (ex: Tylenol, Zantac, Claritin, Dulcolax) you take.________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________

NUTRACEUTICALS (Nutritional supplements [vitamins/minerals], herbals, and homeopathic remedies)Please mark all nutraceuticals that you take.

□ Multivitamin/mineral □ Protein shakes (whey/rice/pea)□ B-Complex multivitamins □ Protein bars□ Vitamins A, C, E □ Bone health formula (calcium/Vitamin D)□ Vitamin D or K □ Joint health formula (glucosamine/chondroitin)□ Fish oil (EPA/DHA) □ Liver formulas (milk thistle, artichoke)□ GLA (borage/evening primrose oils) □ Intestinal formulas (glutamine, aloe vera)□ Magnesium or calcium □ Cardiovascular formulas (hawthorn, garlic, B5)□ Pre/Probiotics (friendly flora) □ Vision formulas (bilberry, lutein, zeaxanthin)□ Digestive enzymes □ Athletic performance (creatine, ribose)□ CoQ10 or grape seed extract □ Anti-inflammatory (curcumin, boswellia)□ Minerals: selenium, zinc (other please list) □ Bach flowers or homeopathic remedies□ Amino acids Others:____________________________________________

__________________________________________________HEALTH HABITSWater Intake________ # of 8 oz. glasses/day Caffeine Intake ________ Coffee: # 8 oz. cups/day ________ Tea: 8 oz. cups/day ________ Soda: (regular/diet) # of 12 oz. cans/day ________ Energy drinks: # of cans/day

Drug use (please list) ___________________________________________________________________________________

Energy Drinks________ # of 8 oz. cans/day

Alcohol consumption ________ Beer: # 12 oz. cans per □ day □ week________ Wine: # 5 fl. oz. glasses per □ day □ week________ Liquor: # 1 fl. oz per □ day □ weekTobacco________ Cigarettes: # per day ________ Cigars: # per day ________ Chew: # cans per day

Name _____________________________ Date of Birth ___________ -3-

EXERCISEDo you exercise regularly? □ Yes □ NoIf yes, how many times per week? □ 1-2 days/ week □ 3-4 days/week □ 5-7 days/ weekWhat type of exercise do you perform?

Aerobic, please list activity ____________________________________________________________________ Anaerobic, please list activity___________________________________________________________________ Other:______________________________________________________________________________________

SLEEP PATTERNSWhat time do you go to bed in the evening? _______________ How long does it take you to fall asleeP? □ 0-5 minutes □ 5-15 minutes □ 15-30 minutes □ >30 minutesHow many hours of sleep do you normally get each night? □ 4 or less □ 4-6 □ 6-8 □ 8-10 □ >10When you wake up in the morning do you feel refreshed and ready to go? □ Yes □ NoOn the average, how many times do you wake up during the night? □ None □ 1-2 □ 3-4 □ 5-6 □ >6

Why do you wake up during the night? □ N/A □ Nature calls □ Dreams/nightmares □ External noise □ Other: ___________________________________________________________________________________________Can you fall back asleep after waking up? □ Yes □ NoHave you been diagnosed with a sleep disorder? □ Yes □ No

STRESSWhat level of stress are you experiencing on a scale of 1 – 10 (1 being the lowest and 10 highest)□ 0 □ 1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9 □ 10Please identify your major causes of stress:□ Work □ Finances □ Legal issues □ Family □ Health issues □ Aging parentsOther: ___________________________________________________________________________________________Do you have an avenue to release your stress? □ Yes □ No

NUTRITIONDo you consume (choose one):

□ Mixed foods (animal and fruit/vegetable sources)□ Strict Vegetarian (no meats, fish, dairy)□ Mixed vegetarian (consumes dairy or fish)□ Are you on a restricted diet (salt, fat, calories) _____________________________________________________

Meat Intake (beef, chicken, fish, turkey, eggs, cheese) How many servings/day (1 serving = 1 oz. meat, 1 egg, 1 slice cheese) ________________________________Is your meat: □ High fat meat (bacon, hot dogs, sausage, regular cheese)

□ Medium fat meat (fried fish, eggs, prime beef, chicken w skin)□ Lean (select beef, egg whites, pork loin/roast, low fat cheese)

Is your meat: □ Conventional □ Natural □ Organic

Dairy Intake (milk/rice & soy, yogurt)How many servings/day (1 serving = 1 cup milk/yogurt) __________________________________

Is your dairy: □ Conventional □ Natural □ Organic Fat content: □ Non-fat □ 1-2% □ Whole

Name _____________________________ Date of Birth ___________ -4-

Fruit/Vegetable IntakeHow many servings of fruit/day (1 serving = 4 oz. juice or 1 small size fruit): ________________________________How many servings of vegetable/day (1 serving = ½ cup cooked vegetable or 1 cup raw) _________________________Are your fruits/vegetables: □ Conventional □ Organic Are your fruits/vegetables: □ Fresh □ Frozen □ Canned

Carbohydrate IntakeHow many servings/day (1 serving = 1 slice bread, ½ cup cereal, 1/3 cup cooked rice, 6 crackers) __________________

Do you eat white breads, white pasta, white rice? □ Yes □ NoDo you eat whole grain breads, pasta, rice? □ Yes □ NoDo you eat gluten free grains? □ Yes □ No

Fat IntakeHow many servings/day (1 serving = 1 tsp oil/margarine/butter, 1 tbsp salad dressing, 6-8 nuts, 2 tsp mayonnaise, 1 slice bacon, 1 tbsp of seeds) _____________________

□ Food Allergies (chest pain, trouble breathing/swallowing, drop in blood pressure, rash, hives)Please list: _______________________________________________________________________________________________

□ Food Intolerance/Sensitivity (gas/bloating, constipation/diarrhea, headaches, irritable/nervousness)Please list: _______________________________________________________________________________________________

DENTAL HISTORYDo you currently have metal amalgam fillings? □ Yes □ No If yes, how many? ______ Have you had your metal amalgam fillings removed? □ Yes □ No If yes, how many? ______ Do you have any cavities? □ Yes □ No If yes, how many? ______ Have you ever had a root canal? □ Yes □ No If yes, how many? ______ Do your gums bleed easily when brushing or flossing? □ Yes □ NoDo you have crowns or bridges? □ Yes □ No If yes, what material are they made of (gold,

nickel, ceramic)? ____________________Have you had extensive surgery to your teeth/jaw? □ Yes □ No If yes, please describe: _________________

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SCARS ON THE BODY Please check off all areas below that are pertinent to scarring on your body. □ Body piercing (ears, belly button, tongue, etc.) □ Episiotomy or C-section□ Surgical or laparoscopic scars □ Stitches□ Tattoos □ Vaccination or insulin injection site scars□ Cuts or scrapes that did not heal properly Other (please list): _______________________________________

HEALTH HISTORY

VACCINATIONSDid you receive all your recommended childhood vaccinations? □ Yes □ No □ UncertainDo you obtain yearly influenza (flu) vaccinations? □ Yes □ NoHave you received special vaccinations for travel? □ Yes □ No(Ex: Malaria, Typhoid, or Yellow fever) Other vaccinations received (HPV, Shingles, Hepatitis A &B) □ Yes □ No

Name _____________________________ Date of Birth ___________ -5-

TRAVEL Please list all areas of travel outside the United States includes; US Virgin Islands, Caribbean Islands, Mexico, Europe, Asia, and cruises taken.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EMOTIONAL TRAUMAPlease list any areas of your life that have been affected by emotional trauma (Ex:, loss of a loved one, family/friends with an illness, loss of a pet, lack of friends, feeling of worthlessness). Has this experience affected your health?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HOBBIES/INTERESTSPlease list what you enjoy doing to relax and have fun? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDITIONAL DOCUMENTATION NOTES (for office use only)

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Name _____________________________ Date of Birth ___________ -6-

Print this form and bring it completed to your appointment.