Health Questionnaire

Kindo Integrated Health Center

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:

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.

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?

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:

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?

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?

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?

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?

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:

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

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:

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?

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?