Adult Medical History Please complete the form below or click the button below for a printable .pdf Print and Complete The Form PERSONAL INFORMATION Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Work Phone (###) ### #### Cell Phone (###) ### #### Email * Age Birth Date MM DD YYYY Gender Assigned at Birth Choose One Male Female What is Your Current Gender Place of Birth Race/National/Ethnic Roots Height Weight Choose One Right-handed Left-handed Mixed Dominance Occupation HEALTH INSURANCE INFORMATION *Please note: We do not accept any health insurance. You are responsible for submitting your own claims. Primary Health Insurance ID/Group # Secondary Health Insurance OTHER Primary Care Physician Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Your local Pharmacy Phone 4 (###) ### #### Address 2 Address 1 Address 2 City State/Province Zip/Postal Code Country GENERAL Referred by? What brings you to our office today? What do you hope to get from today’s visit? MEDICAL HISTORY PRIMARY DOCTOR (S) Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY Name First Name Last Name Phone 6 (###) ### #### Address 4 Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY Name First Name Last Name Phone (###) ### #### Address 5 Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY SPECIALISTS Name First Name Last Name Specialty Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY Name First Name Last Name Specialty Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY Name First Name Last Name Specialty Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY NUTRITIONIST Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY NATUROPATH(S) and/or HOMEOPATH(S) Name First Name Last Name Phone 12 (###) ### #### Address 10 Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY THERAPIST Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Visit MM DD YYYY OTHER Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country CURRENT HEALTH CONCERNS What are you major CURRENT health problems? Problem and Brief Description Date of Onset MM DD YYYY Frequency Choose One Daily Weekly Other Severity Choose One Mild Moderate Severe Problem and Brief Description Date of Onset MM DD YYYY Frequency Choose One Daily Weekly Other Severity Choose One Mild Moderate Severe How much time have you lost from work or school in the past year? Why? PAST MEDICAL HISTORY *Include any chronic/recurring disorder or previously treated problems/diseases which no longer affect you. Examples of chronic/recurring disorders – Recurrent Fungal Infections, Diabetes Mellitus, Chronic Fatigue, etc. Examples of treated problems that no longer affect you – Tuberculosis, Meningitis, etc. Condition(s) Past Treatment(s) Current Treatment(s) Approximate Date(s) of Treatment Do you have a history of Learning Problems? _________ If yes, please provide details (including how they were addressed) WHAT MEDICATIONS ARE YOU TAKING NOW? Name First Name Last Name Dosage and # Per Day Response Choose One Good Response No Response Bad Response Good Then Bad Name First Name Last Name Dosage and # Per Day Response Choose One Good Response No Response Bad Response Bad Then Good Name First Name Last Name Dosage and # Per Day Response Choose One Good Response No Response Bad Response Good Then Bad WHAT VITAMINS, MINERALS and OTHER NUTRITIONAL SUPPLEMENTS ARE YOU TAKING NOW? Name and Form (e.g. Calcium Carbonate vs. Calcium Citrate) Dosage (mg, mcg, IU, etc) and # Per Day Response Choose One Good Response No Response Bad Response Bad Then Good Name and Form (e.g. Calcium Carbonate vs. Calcium Citrate) Dosage (mg, mcg, IU, etc) and # Per Day Response Choose One Good Response No Response Bad Response Bad Then Good Name and Form (e.g. Calcium Carbonate vs. Calcium Citrate) Dosage (mg, mcg, IU, etc) and # Per Day Response Choose One Good Response No Response Bad Response Bad Then Good OTHER MEDICATIONS AND SUPPLEMENTS Please list any other medications you have TAKEN IN THE PAST? Specifically indicate any frequent use of antibiotics and/or steroids. Also, please comment as to whether you had good, bad or no response to each medication Current medication(s) Previous supplement(s) Current supplement(s) Have you ever used CHELATING AGENTS? If yes, please specify name, dose, route, frequency of use, reason for use, and approximate dates of starting and stopping treatment. HEALTH MAINTENANCE UPDATE Physical Examination Date MM DD YYYY Results Eye Exam Date MM DD YYYY Results Dental Exam Date MM DD YYYY Results Breast Exam Date MM DD YYYY Results Digital Rectal Exam Date MM DD YYYY Results Stool Occult Blood Date MM DD YYYY Results Cholesterol Profile Date MM DD YYYY Results Bone Density (DEXA) Scan Date MM DD YYYY Results Mammogram Date MM DD YYYY Results PSA Date MM DD YYYY Results Colonoscopy or Flexible Sigmoidoscopy Date MM DD YYYY Results PAP Test Date MM DD YYYY Results Cardiac Stress Test (Specify Type) Date MM DD YYYY Results Hearing Test Date MM DD YYYY Results SURGICAL HISTORY Chronologically list major/minor surgeries you have had or are planning – include approximate dates and complications. Any major accidents of injuries? Please describe. FEMALE HEALTH HISTORY Age at first period Date of last period MM DD YYYY Length of cycles History of irregular/abnormal periods? Choose One Yes No If yes, please describe Please check if you have a history of Endometriosis Fibroids Polycystic Ovarian Syndrome? Describe any premenstrual symptoms Do you have a history of abnormal PAP tests? Choose One Yes No If yes, please describe Are you taking birth control pills? Choose One Yes No If yes, for how long? If no, have you ever taken them? Any known history of Infertility problems? Choose One Yes No If yes, please explain Pregnancies None Term Births Miscarriages Abortion Preemies Birth weight of largest baby Smallest baby Are you currently pregnant? Choose One Yes No If so, what is your due date? MM DD YYYY If you have never been pregnant, do you wish to have children in the future? Choose One Yes No If you have children, do you plan to have more? Choose One Yes No Illnesses or complications during pregnancy or labor and delivery Medications taken during pregnancy or labor and delivery If you have ever had a C-Section, please explain Any complications for you after delivery? Did you (or do you plan to) breast feed your children? Choose One Yes No Do you take any prescription medications or natural substances for peri- or post-menopausal symptoms? Choose One Yes No If yes, provide names, dosages, etc? Any history of breast problems (tenderness, cysts, etc.)? Any history of yeast infections? If yes, please explain. EARLY HEALTH HISTORY Did your mother have any known problems during her pregnancy with you (illness, stress, medications, smoking, vaccines, alcohol)? Were you breastfed or bottle-fed? If breastfed, please indicate duration Did you have any significant stresses in childhood or adolescence? If yes, please explain Please check if you had any of the following childhood illnesses? Frequent Ear, Throat or other Infections Colic Reflux Meningitis Thrush Asthma Chicken Pox Eczema Frequent Colds Other Did you take either of these medications frequently? Antibiotics Steroid Did you ever have adverse reactions to vaccines? If yes, explain Did you have a problem with bed-wetting? Until what age? FAMILY HISTORY List any allergies, major illnesses, genetic diseases or problems (such as digestive issues or mental health problems) for each family member. **If any family members are deceased, please also list their age at death and cause Mother Father Siblings Maternal Grandparents Paternal Grandparents Others Are you or anyone in your family ADOPTED? If yes, please specify who. SOCIAL AND LIFESTYLE HISTORY With whom do you live? Include children, parents, relatives, friends, etc. and their ages. Recent changes, major losses, births, deaths, divorce, remarriage, moves, etc. List the three (3) major STRESSORS in your life? What is your greatest fear? Describe any RELAXATION/stress management TECHNIQUES you use How important is RELIGION/SPIRITUALITY in your life? How many hours of SLEEP per night do you average? Any difficulty falling asleep or waking up? Choose One Yes No Quality of sleep? Choose One Well rested Tired upon awakening Nighttime awakenings EXERCISE Type Frequency Recent TRAVEL (location, duration, vaccines prior to travel or illnesses during/after that you think relate to the travel): ALCOHOL Choose One Yes No Never If yes, frequency Any alcoholics in your family? Choose One Yes No TOBACCO Choose One Yes No Never Smoked or Smoking packs/day from age _____ to If still smoking, have you ever tried to quit? Choose One Yes No If yes, what methods? Illicit DRUG use? Choose One Yes No Never Used from/ to Route (IV, snort, etc.)? What are your general EATING HABITS (overeat, under eat, picky, etc.)? Do you consider yourself Choose One Obese Overweight Healthy/average weight Underweight Unhealthy weight Have you been on any diets? Please explain (including results and patterns of loss and gain) Have you ever had an eating disorder? If yes, which ones (s)? DIETARY/NUTRITIONAL/DIGESTIVE HISTORY Are you currently following a special diet? Please explain Have you tried Gluten Free Casein Free Yeast Free Salicylate Free Atkins South Beach Low Phenols IgG reactive food avoidance Specific Carbohydrate Diet Low Protein Other Your diet % for the following: Organic/Fresh Food Processed Food Fast Food Other Known food allergies Suspected food SENSITIVITIES Food CRAVINGS (e.g. bread, pasta, cheese, salty foods, sodas/coffee/tea with or without caffeine, alcohol, milk, etc.) FOODS YOU EAT – Place a √ in the appropriate column Cookies Daily > Once per Week Rarely Never Used to Eat Candy Daily > Once per Week Rarely Never Used to Eat Sweets in general Daily > Once per Week Rarely Never Used to Eat Caffeine (soda, tea, coffee) Daily > Once per Week Rarely Never Used to Eat Milk – Specify Type (e.g. cow’s, rice, soy, etc. and whole, 2%, 1% or skim) Daily > Once per Week Rarely Never Used to Eat Ice Cream Daily > Once per Week Rarely Never Used to Eat Salty Foods Daily > Once per Week Rarely Never Used to Eat Meat Daily > Once per Week Rarely Never Used to Eat Pasta Daily > Once per Week Rarely Never Used to Eat Bread – Specify Type Daily > Once per Week Rarely Never Used to Eat Vegetables Daily > Once per Week Rarely Never Used to Eat Fruits Daily > Once per Week Rarely Never Used to Eat Fried Foods Daily > Once per Week Rarely Never Used to Eat Grains Daily > Once per Week Rarely Never Used to Eat Describe your stool pattern (frequency, color, odor, consistency) Do you or have you ever had gastrointestinal problems? Please describe. ENVIRONMENTAL/ALLERGY HISTORY LOCATION Choose One City Suburban Wooded Farm Other WATER Choose One City Well If you have a purification system, please describe Type of HEAT Choose One Electric Gas Oil Other Do you live near Choose One Power lines Woods Industrial areas Water Type (ocean, swamp, etc.) Does your home have a lot of Choose One Dust Mold Down/Feather items (pillows, stuffed animals, etc.) Are there specific areas in your home that you suspect have issues? Please describe Bedding Choose One Synthetic Down Feather Mattress cover Flooring Choose One Wall-to-Wall Carpet Area rug Wood Glued down Synthetic Pad Window Treatment Choose One Shades Blinds Thin curtain Valence Other What is your occupation? Have you had any known exposure to harmful chemicals? List any pets you have in that home Do you have any known ALLERGIES to food and/or medications? If yes, please list names and describe reactions Are you sensitive to any of the following? Check where appropriate. Perfumes/Cosmetics Cleaning Products Mold Paint Pollens/Grasses Soaps Animals (dander) Detergents Dust Gasoline Tobacco Smoke Other Are there foods that you avoid because of how they make you feel? Please explain. SIGNS AND SYMPTOMS Please check where appropriate. Fatigue Choose One Current Past Severity Choose One Choose One Mild Moderate Severe Details Difficulty falling asleep Choose One Current Past Severity Choose One Mild Moderate Severe Details Difficulty staying asleep Choose One Current Past Severity Choose One Mild Moderate Severe Details Daytime sleepiness Choose One Current Past Severity Choose One Mild Moderate Severe Details Heat intolerance Choose One Current Past Severity Choose One Mild Moderate Severe Details Cold intolerance Choose One Current Past Severity Choose One Mild Moderate Severe Details Flushing Choose One Current Past Severity Choose One Mild Moderate Severe Details Headache – Specify Type Choose One Current Past Severity Choose One Mild Moderate Severe Details Low self esteem Choose One Current Past Severity Choose One Mild Moderate Severe Details Trouble remembering Choose One Current Past Severity Choose One Mild Moderate Severe Details Seizures Choose One Current Past Severity Choose One Mild Moderate Severe Details Anxiety Choose One Current Past Severity Choose One Mild Moderate Severe Details Depression Choose One Current Past Severity Choose One Mild Moderate Severe Details Panic attacks Choose One Current Past Severity Choose One Mild Moderate Severe Details Suicidal thoughts Choose One Current Past Severity Choose One Mild Moderate Severe Details Fainting Choose One Current Past Severity Choose One Mild Moderate Severe Details Difficulty with concentration Choose One Current Past Severity Choose One Mild Moderate Severe Details Sore throat Choose One Current Past Severity Choose One Mild Moderate Severe Details Congestion Choose One Current Past Severity Choose One Mild Moderate Severe Details Dark circles/puffiness under eyes Choose One Current Past Severity Choose One Mild Moderate Severe Details Sinus infections Choose One Current Past Severity Choose One Mild Moderate Severe Details Post nasal drip Choose One Current Past Severity Choose One Mild Moderate Severe Details Bad breath Choose One Current Past Severity Choose One Mild Moderate Severe Details Cough Choose One Current Past Severity Choose One Mild Moderate Severe Details Wheezing Choose One Current Past Severity Choose One Mild Moderate Severe Details Seasonal allergies Choose One Current Past Severity Choose One Mild Moderate Severe Details Palpitations Choose One Current Past Severity Choose One Mild Moderate Severe Details Varicose veins Choose One Current Past Severity Choose One Mild Moderate Severe Details Heart attack Choose One Current Past Severity Choose One Mild Moderate Severe Details TMJ problems Choose One Current Past Severity Choose One Mild Moderate Severe Details Muscle weakness Choose One Current Past Severity Choose One Mild Moderate Severe Details Muscle stiffness Choose One Current Past Severity Choose One Mild Moderate Severe Details Joint stiffness Choose One Current Past Severity Choose One Mild Moderate Severe Details Joint pain Choose One Current Past Severity Choose One Mild Moderate Severe Details Cold sores Choose One Current Past Severity Choose One Mild Moderate Severe Details Cracking at corner of lips Choose One Current Past Severity Choose One Mild Moderate Severe Details Nausea Choose One Current Past Severity Choose One Mild Moderate Severe Details Vomiting Choose One Current Past Severity Choose One Mild Moderate Severe Details Abdominal pain Choose One Current Past Severity Choose One Mild Moderate Severe Details Bloating Choose One Current Past Severity Choose One Mild Moderate Severe Details Belching Choose One Current Past Severity Choose One Mild Moderate Severe Details Diarrhea Choose One Current Past Severity Choose One Mild Moderate Severe Details Constipation Choose One Current Past Severity Choose One Mild Moderate Severe Details Blood in stool Choose One Current Past Severity Choose One Mild Moderate Severe Details Hemorrhoids Choose One Current Past Severity Choose One Mild Moderate Severe Details Eczema Choose One Current Past Severity Choose One Mild Moderate Severe Details Hives Choose One Current Past Severity Choose One Mild Moderate Severe Details Rash Choose One Current Past Severity Choose One Mild Moderate Severe Details Sensitive to bug bites Choose One Current Past Severity Choose One Mild Moderate Severe Details Kidney stones Choose One Current Past Severity Choose One Mild Moderate Severe Details Psoriasis Choose One Current Past Severity Choose One Mild Moderate Severe Details Reflux Choose One Current Past Severity Choose One Mild Moderate Severe Details Other Choose One Current Past Severity Choose One Mild Moderate Severe Details Other Choose One Current Past Severity Choose One Mild Moderate Severe Details Do you have any dental amalgams (silver fillings)? If so, how many? Any history of dental problems? Any plans for special dental procedures in the future? ADDITIONAL SYMPTOMS Describe any other symptoms you would like us to know about you. List any other history, pertinent thoughts or questions you want to address. Thank you!
