Health History
Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank you.
Name *
Your answer
Address *
Your answer
email address *
Your answer
Date of birth *
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DD
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YYYY
Place of birth
Your answer
Phone number
Your answer
Occupation
Your answer
Who referred you to our office?
Your answer
Describe your principal complaint
Your answer
Do you have a diagnosis?
Your answer
Any problems during your birth? If "yes" please explain
Your answer
Vaccination History: Any reactions that you remember? Any unusual vaccinations?
Your answer
Childhood Illness: any surgeries or accidents?
Your answer
List any medications (prescribed and over-the-counter), vitamins, and supplements you are currently taking:
Your answer
Do you have any reason to believe you may be pregnant?
Do you have any infectious diseases? If so, please identify
Your answer
Autoimmune diseases? Which one?
Your answer
Cancer history? What type
Your answer
Please choose all that applies
Allergies? Which ones?
Your answer
Which are your staple foods?
Your answer
Do you eat dairy?
Do you drink caffeinated beverages?
Do you smoke nicotine?
Recreational drugs? Which ones?
Your answer
Exercise
Your answer
Interests and hobbies
Your answer
Thank you for taking your time to fill out this form. Do you have any questions for me?
Your answer
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