Your Health History Please complete the following information prior to your visit: Your name (required) Your email (required) Today's date (required) Your Occupation Your Age Your Height Your Sex Relationship Status SinglePartnerMarriedSeparatedDivorcedWidowed Number of Children Current issue(s) for which you are seeking help (required): Date Issue Began Current issue(s) for which you are seeking help: Date Issue Began Top 5 Health Concerns: Your top 1-5 health concerns? please list. What are your current health goals? Current health goals? What types of therapies have you tried for these problem(s) or to improve your health over‐all? Diet modificationFastingVitamins/MineralsHerbsHomeopathyChiropracticAcupunctureConventional drugsOther Do you experience any of these general symptoms currently? FatigueShortness of breathInsomniaConstipationChronic pain/inflammationDepressionPanic attacksNauseaFecal incontinenceBleedingDisinterest in sexHeadachesVomitingUrinary incontinenceDisinterest in eatingDizzinessDiarrheaLow-grade feverItching/rash What medications are you currently taking? (prescription or over-the-counter) Laboratory procedures performed Stool analysisBlood and urine chemistriesHair analysisOther List other lab procedures: Major Hospitalizations/Surgeries - Please list all procedures, complications (if any) and dates: Physical Injuries, Traumas ‐ recent & past accidents, car accidents, sports injuries, falls, etc: Did you play football or do gymnastics or cheerleading in the past? YesNo Current level of stress (0-10, with 0 being the lowest): 012345678910 Do you consider yourself: overweightunderweightjust right Your weight today? Medical History/Symptom Survey Neurological ADD/ADHDAlcoholismCold feetCold handsDental problemsDepressionDizzinessDrug addictionEating disorderBalance ProblemsEpilepsyEyes, Ears, Nose problemsBlurred visionLight bothers eyesGlaucomaFacial painFacial twitchFaintingFatigueInner tensionIrritabilityLearning disabilitiesLoss of smell or tasteMental illnessNervousnessNeurological problems i.e., Parkinson's, paralysisNumbness/Pins/Needles ArmsNumbness/Pins/Needles LegsRinging in earsSeasonal affective disorder Vital Organs Allergies/hay feverAlzheimer's diseaseAnemiaArthritisAsthmaAuto Immune diseaseBed‐wettingBlood pressure problemsBronchitisBreathing ProblemsCancerChest painCholesterol, elevatedChronic fatigue syndromeCirculatory problemsCold sores/herpesDiabetesEnvironmental sensitivitiesFibromyalgiaGenetic disorderGoutHeart diseaseHIV/AIDSInfection, chronicKidney or bladder diseaseLiver or gallbladder disease (stones)ObesityOsteoporosisPneumoniaSexually transmitted diseaseSinus problemsSkin problemsStrokeSwollen anklesSwollen jointsThyroid troubleUrinary tract infectionVaricose veins Physical Structure Shooting head painPainful shoulder/armPain in neckPain in mid backPain in lower backPainful jointsPain in legs/feetPain or tension in jawCarpal tunnel syndromeSpinal curvatureMigraine headachesMuscle spasmsGrinding in neckHernia Digestion Stomach troubleColitisConstipationDiverticular diseaseDigestive complaintFood intoleranceGastro-esophageal reflux diseaseIndigestionInflammatory bowel diseaseIntestinal gasIrritable bowel syndromeUlcer Medical (Men) Benign prostatic hyperplasiaProstate cancerDecreased sex driveInfertilitySexually transmitted disease Medical (Women) Menstrual irregularitiesInfertilityFibrocystic breastsFibroids/ovarian cystsPremenstrual syndrome (PMS)Breast cancerDecreased sex driveSexually transmitted diseaseMenopause Are you pregnant? YesNo Mammogram? YesNo Health Habits Tobacco (# per day) Alcohol (# of drinks per day/week) Coffee (# 6 oz cups per day) Tea (# 6 oz cups per day) Soda - caffeinated) (# cans per day) Water (# of glasses per day) Exercise 5-7 days per week3-4 days per week1-2 days per week45 minutes or more duration per workout30-45 minutes duration per workoutLess than 30 minutes durationWalkRun, jog, other aerobicsWeight liftStretch [anr_nocaptcha g-recaptcha-response] Δ
