Health History Form

Congratulations on taking this step. My intention is to serve you in a timely and professional manner, taking into account everything that potentially plays a role in what you’re seeking help for. The purpose of this form is to gather your key, relevant details. Please answer as completely and honestly as you’re able. Your openness helps build a foundation of trust and allows me to offer the most appropriate support. Based on your responses, I may suggest different approaches, interventions, and treatments. I encourage you to hold this form as an important part of the process that can meaningfully contribute to your overall experience, rather than as a task to complete.

All information you provide will be treated as confidential and used only in relation to your care. Your records will be handled in line with data protection standards. You’re welcome to withhold any details that you would prefer to discuss in person; simply leave a note in the relevant section of the form.

Please complete this form at least 48 hours in advance of your initial consultation. Do also send any relevant medical records that you would like to share, such as a physical exam, blood-work, x-rays, and CT scans.
Please commit to the following: I will complete this questionnaire truthfully. I understand that withholding or misrepresenting medical information could result in serious health complications.

    Full Name (required):

    Mobile Phone:

    Email Address (required):

    Address (City, State, Country)

    Age & Date of Birth:

    Place of birth:

    Time of Birth:

    Ethnicity:

    Sex:

    Sexual Orientation:

    Height:

    Weight:

    Relationship status (e.g., single, partnered, married, divorced, widowed):

    Number & age of children and parenting status (e.g., single parenting, co-parenting):

    Religion / Spirituality:

    Education (discipline & degree):

    Occupation:

    Your reason for seeking help.
    For medical conditions, please answer the following questions:
    1. Name of condition
    2. When it first started
    3. How often it bothers you
    4. Severity on a scale from 1-10 (1 = least, 10 = excruciating)
    5. Treatments received and benefits experienced.

    Blood Pressure:

    Have you ever had any of the following?

    Toxic exposures (chemicals, radiation, history of physical abuse, etc.)

    Cancer / tumor

    Diabetes

    Foreign objects in the body (i.e. steel plates, electronic or other implants, etc.)

    Heart disease

    High Blood Pressure

    Pregnancy

    Amalgam fillings

    Eye infections

    Thyroid disease

    Hepatitis

    HIV AIDS

    STI / STD (Sexually Transmitted Infection / Disease)

    Broken bones

    Burns

    Stitches (major)

    Organ removals / transplants

    Loss of consciousness

    History of drug / alcohol abuse

    Other

    Surgeries (minor and major) and Hospitalizations:
    (For pregnancies / miscarriages, include number and dates)?

    List any medications, vitamins, herbal remedies, food supplements, etc. that you are currently using. Include recent/annual shots (flu, allergy) and immunizations:

    Item

    Dosage
    & Frequency

    Reason
    for Use

    Positive
    & adverse effects,
    if any?

    Do you have any known allergic reactions to any medications or other substances (include details)?

    What is your average daily / weekly consumption of the following:

    Water:

    Fruit juices (natural and other):

    Coffee (caffeinated & decaffeinated):

    Tea (caffeinated & decaffeinated):

    Sodas:

    Red meat:

    Poultry:

    Dairy Products:

    Refined sugar (chocolate, candy, etc):

    Alcoholic beverages:

    Period / years of use?

    Cigarettes / cigars/ chewing tobacco:

    Years of use, frequency, and amount?

    Other substances?

    Years of use, frequency, and amount):?

    Exercise (regular indoor / outdoor activities):

    Activity

    Duration

    Frequency

    How soon would you like an appointment?

    What is your typical availability (days and times, including weekends)?

    Which payment option would you like?

    Full paymentReduced feeUnable to pay

     
    Facebook Twitter