Name: Today's Date:
Date of Birth: Place of Birth:
If under 18, parent's name:
Address:
City: State: Zipcode:
Phone (H): Phone (W): Phone (C):
E-Mail Address:

Relationship Status:
    Single and living alone
    Single and living with partner
    Married
Do you have any children?

Please give names and ages:
Occupation:
Referred By:

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Primary Complaint
Please include, briefly, location of complain, time of onset, cause (if known),
factors that aggravate symptoms, and any other pertinent information.


Secondary Complaint


Please list all medications that you are currently taking. Include both natural medicines (eg. herbs,
homeopathic, vitamin supplements, etc.) and prescription drugs

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Are you currently being treated by other health care providers?
Type Name of Doctor and City
Medical Doctor
Chiropractor
Naturopath
Oriental Medicine
Other
What is your blood type?
How would you rate your current level of health? (1 = Very Poor; 10 = Excellent)
    1 2 3 4 5 6 7 8 9 10
How would you rate your current level of energy? (1 = Very Poor; 10 = Excellent)
    1 2 3 4 5 6 7 8 9 10

Energy Levels

Are you fatigued, or do you fatigue easily?
Do you need to take naps?
Do you generally feel cold?
Do you have cold feet or hands?
Do you ever have low grade fever?
Do your hands and feet warm up easily?
Do your feet get warm at nighttime, in bed?
Do you ever wake up sweating during the night?
Men - Do you have ejaculations during your sleep?

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Appetite and Taste

Has your appetite altered recently?
Do you have a poor appetite?
Do you have poor digestion?
Do you have epigastric (stomach) distention?
Do you have abdominal (large intestine) distention?
Are you experiencing belching?
Are you passing gas?


What percentage of your diet is the following:
Animal Protein
Vegetables
Carbohydrates (Bread, Rice, Pasta)
Fruit
Sweets
List any known or suspected food allergies:

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Thirst and Dryness

Do you have dry eyes?
Do you have a dry nose or lips?
Do you have dry skin or hair?
How many glasses of water or fluids do you drink daily?

Stools and Urine

Are your stools:
Normal? (Daily with same shape and size.)
Unusually hard?
Unusually loose?
Erratic in form? (Sometimes hard, sometimes loose.)
Do you have bowel movements less than five times a week (constipation)?
Is there any blood or pus in your stool?
Do you have hemorroids?

Is your urine:
Unusually scanty and dark?
Unusually profuse and clear?
Do you wake more than once a night to urinate?
Do you experience any dribbling of urine?
Do you have urgency to urinate?
Do you experience burning urination?

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Sleep

Do you suffer from insomnia?
Do you have restless sleep?
Do you have uncomfortable dreams?

Emotions

Do you experience:
Anger?
Worry?
Depression?
Fear?
Sadness?
Anxiety?

Structure

Do you suffer from chronic or occasional backache or neck ache?
Do you suffer from chronic or occasional joint pain?
Do any muscles ache or cramp?

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Accidents

Please list all major accidents, including fractures, deep cuts, serious sprains, etc. Please indicate
all head injuries. Include dates or age:

Surgery History

Describe reason, age, and any consequential outcome.
Have you ever had a blood transfusion? What year?

Exercise

What do you do for exercise? How often?

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Disease History

Do your parents have any unusual health problems? If they died, state cause of death and age of death.



During your mother’s pregnancy with you, did she:
Drink alcohol?
Smoke cigarettes?
Suffer serious illness?
Take medications?
Suffer emotionally or physically?

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Please check if you have or have had any of the following:
Now Past Condition Now Past Condition
Anemia Head Injury
Arthritis Headaches
Asthma Heart Murmer
Bruising Heart Palpitations
Cancer Hepatitus Type
Candida Herpes
Cholesterol, High Hypertension
Constipation Kidney Stones
Depression Low Sex Drive
Diabetes Mental Illness
Diarrhea Mononucleosis
Digestive Problems Nose Bleeds
Dizziness, Vertigo Numbness, Neuropathy
Edema Prostate Problems
Epilepsy Sciatic Pain
Food Allergies Skin Problems
Frequent Colds TMJ
Frequent Gas Ulcers
Gallstones Venereal Disease
Hayfever Allergies Parasites (Type and Date):
Any other serious illness, injury or complaint? If so, name:

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Drug History

Now Past Drug Years of Use
Antidepressants, Mood Modifiers
Antibiotics
Antacids (Prilosec, Tagament, etc.)
Asthma Medications
Birth Control Pills
Hormone Replacement Therapy
Pain Medication (Prescription)
Steroids (Prednisone, etc.)
Thyroid Medication

Alcohol (in excess)
Cigarettes
Amphetamines
Cocaine
Heroin
Marijuana

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Women Only

Do you have a history of:
Amenorrhea (long time spans without a period)?
Breast implants. Were they removed?
Chronic vaginal or yeast infections?
DES baby?
Endometriosis?
Hysterectomy? What year?
Infertility?
Irregular periods?
Menstrual cramps?
Miscarriage?
Ovarian cyst (single)?
Polycystic ovaries?
Pelvic Inflammatory Disease (PID)?
Uterine fibroids?

Birth control method (past or present); number of years usage:

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Menstrual History
Are you currently pregnant?
Are you presently suffering from a menopausal disorder?
Have you completed menopause?


If you are still having your periods:
Is your period regular?
How many days between your periods?
How many days does your period last?
Are your periods painful?
Is your ovulation painful?
Do you bleed excessively?
Do you bleed too little?
Do you discharge clots?
Do you get headaches during menstruation or ovulation?
Do you suffer from premenstrual syndrome (PMS)? If yes, please indicate:
Irritability Breast Distention
Headache Water retention
How many days before your period do the PMS symptoms begin?

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Pregnancy History
How many times have you been pregnant?
Do you have difficulty getting pregnant?
Have you had any abortions? How many?
Have you had any miscarriages? How many?
Have you had an ectopic pregnancy?
Did you have difficulty following childbirth?

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