Health History Intake Form Contact InformationPlease be aware this form is extensive. It will probably take a good 30 minutes to complete. Please be thorough. The more time you are willing to spend with this form the more time we will have in your consultation to be effective. Thank you. Last Name First Name Date Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryPhone Email Birth Date Occupation Duration of Occupation Sex Trans-genderFemaleMaleOtherHow did you hear about us? Personal HistoryInstructions When describing your health concerns please include: When each symptom began? How long the symptoms last? Please explain what makes each symptom better or worse?Current Symptoms or Complaints Previous Symptoms or Complaints Surgeries: When and What? Other ConditionsPlease check any conditions you frequently experience: AllergiesSinus ProblemsJoint or Muscle AchesSkin ProblemsHeadachesColdsFluFeversConstipationDiarrheaDizzy SpellsEarachesEdemaRinging in the EarsChillsEye ProblemsSore ThroatAcid RefluxHair LossStiff NeckChest PainsUnconsciousnessEuphoriaDepressionSudden Mood ChangesSudden Loss of EnergyAny other complaints, symptoms, or conditions: Family HistoryMother's Ailments Father's Ailments Maternal Grandmother's Ailments Maternal Grandfather's Ailments Paternal Mother's Ailments Paternal Grandmother's Ailments Children's Ailments As a child were you closer to your mother or your father? Explain: Birth Issues Did your mother have difficulties when pregnant with you?Any difficulties with your delivery?Did your mother have any miscarriages or still births?Were you breast fed?Were you bottle fed?Were you allergic to your formula?Were you allergic to your mom's milk?Were you allergic to your milk as a child?Please explain any birth issues you marked: FearsChildhood Fears Fear of the dark?Being in a dark room?Fear of heights?Fear of animals?Fear of strangers?Were you shy?Fear of insects?Fear of insects?Do you still have any of those fears? Current Fears: Are you afraid of heights?Do heights make you dizzy?Do you ever want to jump while standing in a high place?Are you afraid of animals?Are you afraid of insects?Any other fears? Family Status:Are you married? YesNoDivorcedAt what age were you married? How many marriages? Do you have children? YesNoNot sureHow many children? What age did you have children? Food CravingsWhat do you crave? SweetsChocolateIce CreamMilkPotatoesMeat FatMustardFishMeatsSpicy FoodHorseradishButterSaltOrangesIceFruit JuiceFruitSodaCoffeeLemonsAlcoholTeaWaterOystersEggsSour PicklesMarijuanaPotato ChipsCerealBreadIf everything were healthy for you to eat, what would you most like to eat and drink? What do you mostly eat? What do you mostly drink? What do you mostly dislike to eat or drink? Are there any foods or drinks which cause you discomfort? Environmental ConditionsDo you usually feel warm or cool? YesNoNeitherDo you feel better in warm or cool weather? WarmCoolNeitherWhat time of day do you have the most energy, think the clearest, and feel best? 000102030405060708091011121314151617181920212223HH000510152025303540455055MMWhat is your worst time of day, when you are tired and/or irritable? 000102030405060708091011121314151617181920212223HH000510152025303540455055MMDoes disorganization bother you? YesNoNeitherDo you keep your home neat and tidy? YesNoNeitherCan you throw your clothes on the chair before going to bed? YesNoNeitherAre you bothered by scary movies or unpleasant news on T.V.? YesNoNeitherWhat are you unusually sensitive to? NoiseSmellsLightPerfumeOdor of cooking foodChewing noisesTouchUglinessSuffering of othersTastesSudden movementAnything else you are unusually sensitive to? Do you prefer the companionship of animals over that of people? YesNoNeitherDo you prefer to keep your feelings to yourself or do you like to express them? To my selfI express themNeitherDo you remember injustices a long time? YesNoNeitherDo you experience angry outbursts? YesNoNeitherAfter you've lost control which do you feel? RelievedRemorsefulGuiltyUpsetDepressedStill angryAngry at yourselfHow does consolation from another person make you feel? BetterUncomfortableIrritatedNothingDo you have difficulty making decisions? YesNoNeitherI can't choosePhysical TraitsWhen do you feel better? Doing thingsSitting stillDoing things quicklyDo you exercise? YesNoNeitherWhat do you do for exercise? Do you feel better if you exercise? YesNoNeitherAre your symptoms better or worse before a rainstorm? YesNoNeitherIs your mouth often dry? YesNoNeitherWhen are you thirsty? DayNightNeverAlwaysHow do you prefer your drinks? ColdIce coldHotRoom TemperatureDo you have any difficulty swallowing liquids, solids, dry swallowing? Please describe, when, how, under what conditions? How do you drink your liquids? SlowlyIn gulpsRapidlyIn small sipsBowel HabitsAre you frequently constipated? YesNoNeitherDoes your constipation make you uncomfortable? YesNoNeitherDo you often have diarrhea and if so when? how long after eating until you get gassy or have abdominal distension? Do you become gassy or have abdominal distension? YesNoNeitherDo you have loose bowels when you are nervous? YesNoNeitherCan you be relieved by belching? YesNoNeitherCan you be relieved by passing gas? YesNoNeitherWhen you pass gas is it foul smelling? YesNoNeitherHow often do you get up to urinate at night? Do you void a large amount on urination? YesNoModerateAre you bothered by clothes touching or pressing against your abdomen? YesNoSlightlyAre you bothered by clothes pressing against your neck? YesNoSlightlySleep PatternsDo you have difficulty falling asleep? YesNoNeitherDo you have difficulty returning to sleep? YesNoNeitherHow do you feel while sleeping? HotColdSweatyWarmRestlessAnxiousFearfulI'm in painWonderfulI wake frequentlyParts of me go numbI don't feel as if I sleepWhen you sleep at night do you want the room to be? WarmCoolQuietWhite noise in the backgroundMoving airAll windows openFan directly on my faceCovered up completelyJust a light sheet over meElectric blanket on meDo you feel worse in the evening? YesNoSometimesDo you feel worse at night? YesNoSometimesDescribe meaningful or unusual dreams you had as a child: Describe meaningful or unusual dreams you had recently: Do you feel worse in the morning? YesNoSometimesPast ConditionsHave you had any type of itchy skin rash in the past? If so when? What? Please describe: Have you had a blow to the head or a concussion? If so when? Please describe: How do you feel about your sex life? EnjoyDislikeIndifferentNon-existantRather not sayHave you had thoughts of suicide? If so when? What happened? The thing that most concerns me is? I want most to have relief from? Women's SectionAt what age did your period begin? Was your period regular? YesNoSometimesIs your period regular now? YesNoSometimesHave you ever had any major problems with your periods? If so when? Please describe: How long does your period last? Please describe the quality of your period: Is there clotting? What is the color? Etc. Men's sectionHave you had any problems with your prostate? YesNoMinorSometimesDo you have any blood in your urine? YesNoSometimesIf you have blood in your urine when did it start? Please describe: Do you have any problems with impotence? When does this occur? If so please describe: Current MedicationsPlease list any current medications you are taking including supplements and/or herbs: Please list any past medications which you were on for a long time and/or you feel are still affecting you: Is there anything else you would like to let us know about your health? Please attach any health records you would like us to review. Congratulations you are done with this form. We appreciate your time and we will spend time reviewing it for you. Please submit it to us. We look forward to partnering with you soon! VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
