Health History Form

Note: Our intention is to serve you in a timely and professional manner, taking into account everything that potentially plays a role in what you are coming in for. The primary purpose of this form is to gather the most important information about your health. This information will be placed in your personal file that belongs to you. It is strictly confidential. This information will only be seen by your practitioner. It will not be seen by any other individual, company or agency without written consent from you, upon request. Please bring any relevant medical records, such as a physical exam, blood-work, x-rays, CT scans, etc., with you on your first visit.

Date:

Full Name (required):

Home Phone:

Work Phone:

Mobile Phone:

Email Address (required):

Full Address (Street, City, State & Zip)

Age & Date of Birth:

Place of birth:

Time of Birth:

Gender:

Race:

Height:

Weight:

Blood Type:

Blood Pressure:

Marital Status:

Occupation:

Education (field / discipline):

State your reason for coming to us (if it is a medical condition, also answer the following three questions):

How long have you had this condition?

How often does it bother you?

On a scale from 1-10, rate the severity
(1 = least severe; 10 = excruciating):

Please list all the types of treatment you have had for this issue and whether or not you benefited (include relevant details):

Do you have or have you ever had any of the following?
 Toxic exposures (chemicals, radiation, history of physical abuse, etc.)

 Cancer / tumor

 Diabetes

 Foreign objects in the body (i.e. steel plates, electronic or other implants, etc.)

 Heart disease

 High Blood Pressure

 Pregnancy

 Amalgam fillings

 Eye infections

 Thyroid disease

 Hepatitis

 HIV AIDS

 STDs (sexually transmitted diseases)

 Broken bones

 Burns

 Stitches (major and minor)

 Organ removals / transplants

 Loss of consciousness

 History of drug / alcohol abuse

Other

Surgeries (minor / major) / Hospitalizations:
(For pregnancies, include number and dates, as well as miscarriages)?

List any medications, vitamins, herbal remedies, food supplements, etc. that you are currently using. Include recent/annual shots (flu, allergy) and immunizations:

Item Dosage
& Frequency
Reason
for Use
Positive
& adverse effects,
if any?


Do you have any known allergic reactions to any medications or other substances (include details)?

What is your average daily / weekly consumption of the following:

Water:


Fruit juices (natural and other):


Coffee (caffeinated & decaffeinated):


Tea (caffeinated & decaffeinated):


Sodas:


Red meat:


Poultry:


Dairy Products:


Refined sugar (chocolate, candy, etc):


Alcoholic beverages:


Period / years of use?


Cigarettes / Cigars:


Period / years of use?


Other substances?


Period / years of use?

Exercise (regular indoor / outdoor activities):

Activity Duration Frequency

Which payment option would you like?
 Full payment (cash, check/MO, or credit/debit) Partial payment Unable to pay