Name: ____________________________________
Date: ___________________
Social Security Number: ____________________________
Date of Birth: ___________________
Age: _____________
Gender: ___________
Occupation: _________________________
Height: ______________
Marital Status: ___________________
Weight: ______________
Number of Children: ________________
Address: ________________________________________________________________
Day Phone: ______________________
Evening Phone: ______________________
Email: _______________________________
Cell Phone: ______________________
Preferred Method of Contact: _______________________________________________
Primary Care Physician: ________________________
Employer’s Name: __________________________
Number: _________________
Number: ___________________
Employer’s Address: ______________________________________________________
Please complete the the best of your knowledge/ability. Any information or questions you
are unclear about please indicate with a question mark.
1. What brings you here today?
____________________________________________________________________
____________________________________________________________________
2. What are your top three health concerns that you would like to address?
1)_____________________________________________________________
2)_____________________________________________________________
3)_____________________________________________________________
Are any of these adversely affecting your quality of life?
____________________________________________________________________
____________________________________________________________________
3. What do you hope to get from working together?
____________________________________________________________________
____________________________________________________________________
4. If applicable, please list any foods, drugs, or medications you are hypersensitive or
allergic to (please include reaction):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5. Please list any medications (prescribed and over-the-counter), vitamins, and
supplements you are currently taking:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6. Do you have any infectious diseases?
Y
N
If yes, please identify:
_____________________________________________________
7. Blood Pressure: What is your most recent blood pressure reading? _______/_______
When was this reading taken? _______________
8. Childhood Illness (please circle any that you have had):
Scarlet Fever
Measles
Diphtheria
German Measles
Rheumatic Fever
Chicken Pox
Mumps
Strep Throat
9. Hospitalizations and Surgeries
Reason
When
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
10. X-Rays/CAT Scans/MRI’s/NMR’s/Special Studies
Reason
When
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
11. Emotional (please circle any that you experience now and underline any that you have
experienced in the past):
Mood Swings
Anxiety
Nervousness
Depression
Mental Tension
Bipolar Disorders
Other:
__________________________________________________________________
12. Energy and Immunity (please circle any that you experience now and underline any that
you have experienced in the past):
Fatigue
Slow Wound Healing
Chronic Infections
Chronic Fatigue Syndrome
Other:
_________________________________________________________________
13. Head, Eye, Ear, Nose, and Throat (please circle any that you experience now and
underline any that you have experienced in the past):
Impaired Vision Eye Pain/Strain Glaucoma Hay Fever Glasses/Contacts
Tearing/Dryness Impaired Hearing
Ear Ringing Earaches
Headaches Sinus Problems Nose Bleeds Frequent Sore Throat
14. Respiratory (please circle any that you experience now and underline any that you have
experienced in the past):
Pneumonia Frequent Common Colds Difficulty Breathing Asthma
Tuberculosis
Emphysema Persistent Cough Pleurisy Shortness of Breath
15. Cardiovascular (please circle any that you experience now and underline any that you
have experienced in the past):
Heart Disease Chest Pain Swelling of Ankles High Blood Pressure Murmur
Palpitations/Fluttering
Arrhythmia Myocardial Infraction Stroke
16. Gastrointestinal (please circle any that you experience now and underline any that you
have experienced in the past):
Ulcers Nausea/Vomiting Constipation Diarrhea Heartburn Hemorrhoids
Abdominal Pain
Gall Bladder Disease
Liver Disease
Hepatitis B or C
17. Genito-Urinary Tract (please circle any that you experience now and underline any
that you have experienced in the past):
Kidney Disease
Painful/Impaired Urination
Frequent UTI
Blood in Urine
Frequent Urination/At Night
Heavy Urinary Flow
Kidney/Bladder Stones
18. Female Reproductive/Anatomy (please circle any that you experience now and underline
any that you have experienced in the past):
Irregular Cycles Breast Lumps/Tenderness
Nipple Discharge Heavy Flow
Vaginal Discharge
Premenstrual Problems
Bleeding Between Cycles
Clotting
Menopausal Symptoms
Painful Periods
Difficulty Conceiving
19. Menstrual/Birthing History
Do you have any reason to believe you may be pregnant?
Y
N
If so, how far along are you?
____________________________________________________________________
Age of First Menses: __________
Length of Cycle: __________
Number of Pregnancies: ___________
Number of Miscarriages: ___________
Number of Days of Flow: __________
Quality of Flow: ____________
Number of Live Births: ___________
Number of Abortions: ___________
20. Male Reproductive (please circle any that you experience now and underline any that
you have experienced in the past):
Sexual Difficulties
Prostrate Problems
Testicular Pain/Swelling
Penile Discharge
Nocturnal Emissions
21. Musculoskeletal (please circle any that you experience now and underline any that you
have experienced in the past):
Neck/Shoulder Pain
Joint Pain
Muscle Spasms/Cramps
Arm Pain/Leg Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
What is the quality of the Pain?
____________________________________________________________________
Is there anything that makes it better?______________________________________
Worse?______________________________________________________________
22. Neurologic (please circle any that you experience now and underline any that you have
experienced in the past):
Vertigo/Dizziness Paralysis Numbness/Tingling Seizures/Epilepsy
23. Endocrine (please circle any that you experience now and underline any that you have
experienced in the past):
Hypothyroid
Hypoglycemia
Hyperthyroid
Diabetes Mellitus
Night Sweats
Feeling Hot or Cold
24. Other (please circle any that you experience now and underline any that you have
experienced in the past):
Anemia Cancer Rashes Eczema/Hives Cold Hands/Feet
Is there anything else I should know, or you would like to talk about?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Lifestyle:
Do you typically eat at least three meals per day?
Y
N
If no, how many? ___________________
Do you follow a specific diet?
___________________________________________________________
How do you typically feel after eating?
____________________________________________________________
____________________________________________________________
Overall Energy Level:
____________________________________________________________
____________________________________________________________
Exercise routine:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Spiritual practice:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Nicotine/Alcohol/Caffeine Use:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Other Recreational Drug Use:
How many hours per night do you sleep? ________
Do you wake rested?
Y
N
Do you dream? What is the nature of your dreams?
____________________________________________________________
____________________________________________________________