Name *
Name
Date *
Date
Medical History
Please provide the date you were diagnosed with any of the following conditions.
Diabetes
Diabetes
High Blood Pressure
High Blood Pressure
Thyroid Disease
Thyroid Disease
Cancer
Cancer
HIV
HIV
High Cholesterol
High Cholesterol
High Blood Pressure
High Blood Pressure
Seizures
Seizures
Hepatitis
Hepatitis
Surgical History
Family History
Please indicate whether members of your family have been diagnosed with the following conditions. Check any/all that apply.
Heart Disease
Cancer
Hypertension
Stroke
Asthma
Allergies
Migraines
Depression
Other Mental Illness
Substance Abuse
Osteoporosis
Diabetes
Glaucoma
For Women
Are you pregnant now?
Date of last Pap Smear:
Date of last Pap Smear:
Any history of abnormal Pap Smear?
Date of last Mammogram:
Date of last Mammogram:
Is your menses cycle regular?
The flow is:
The color is:
Do you have the following menstruation related signs/symptoms? Check any/all that apply.
for men
Do you have any bothersome urinary symptoms?
Check any/all that apply:
Do you get up at night to urinate?
Medications and Supplements
Allergies
Nutrition
Do you follow a special diet?
Social History
Have you ever had a problem with alcohol or alcoholism
Have you ever had a problem with dependency on other drugs?
Do you have a known history of any exposure to toxic substances?
Do you exercise?
Do you awake feeling rested?
Do you feel you sleep well at night?
Other Information
Have you been treated for emotional issues?
Have you ever considered or attempted suicide?
Do you have any other neurological or psychological problem?
general health
Check any/all that apply:
Poor appetite
Excessive appetite
Insomnia
Fatigue
Fevers
Night sweats
Chills
Localized weakness
Poor coordination
Bleed or bruise easily
Catch cold easily
Change in appetite
Strong thirst
skin and hair
Check any/all that apply:
Rashes
Hives
Itching
Exzema
Pimples
Dryness
Tumors, lumps
Head and Neck
Check any/all that apply:
Dizziness
Fainting
Neck stiffness
Enlarged lymph glands
Headaches
Concussions
Ears
Check any/all that apply:
Infection
Ringing
Decreased hearing
Eyes
Check any/all that apply:
Blurred vision
Visual changes
Poor night vision
Spots
Cataracts
Glasses/contacts
Eye inflammation
nose, throat, mouth
Check any/all that apply:
Nose bleeds
Sinus infections
Hay fever or allergies
Recurring sore throat
Grinding teeth
Difficulty swallowing
Cardiovascular
Check any/all that apply:
High blood pressure
Low blood pressure
Blood clots
Palpitations
Phlebitis
Chest pain
Irregular heart beat
Cold hands/feet
Fainting
Difficulty breathing
Swelling of hands/feet
Respiratory
Check any/all that apply:
Asthma
Bronchitis
Frequent colds
Chronic obstructive pulmonary disease
Pneumonia
Cough
Coughing blood
Production of phlegm
Gastro-intestinal
Check any/all that apply:
Nausea
Vomiting
Diarrhea
Belching
Blood in stool/black stool
Bad breath
Rectal pain
Hemorrhoids
Constipation
Pain or cramps
Indigestion
Gall bladder disorder
Gas
Genito-urinary
Check any/all that apply:
Kidney stones
Painful urination
Frequent urination
Blood in urine
Urgency to urinate
Inability to hold urine
Male
Check any/all that apply:
Pain/itching genitalia
Genital lesions/discharge
Impotence
Weak urinary stream
Lumps in testicles
Female
Check any/all that apply:
Frequent urinary tract infections
Frequent vaginal infections
Pain/itching of genitalia
Genital legions/discharge
Pelvic inflammatory disease
Abnormal pap smear
Irregular menstrual periods
Painful menstrual periods
Premenstrual syndrome
Abnormal bleeding
Menopausal syndrome
Breast lumps
Hot flashes
Neurological
Check any/all that apply:
Seizures
Tremors
Numbness/tingling of limbs
Concussion
Pain
Paralysis
Psychological
Check any/all that apply:
Depression
Anxiety/stress
Irritability
Treated for emotional or psychological problems
Infection screening
Check any/all that apply:
HIV
TB
Hepatitis
Gonorrhea
Chlamydia
Syphilis
Genital warts
Herpes: oral
Herpes: genital
Muscular-skeletal
Check any/all that apply:
Stiff neck/shoulders
Low back pain
Back pain
Muscle spasm/twitching/cramps
Sore, cold, or weak knees
Joint pain