Confidential Patient Information Page 2
ADVERTISEMENT
1
2
3General Health History
Often times, accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this
as it will help us help you!
Have you had any surgery? (Please include all surgery)
1. Type:
When?
2. Type:
When?
3. Type:
When?
Have you had any accidents and/or injuries: auto, work-related, or other? (Especially those related to your present problems).
□
□
1. Type:
When?
Hospitalized? Yes
No
□
□
2. Type:
When?
Hospitalized? Yes
No
□
□
3. Type:
When?
Hospitalized? Yes
No
□
□
Do you wear orthotics or heel lifts? Yes
No
Current Medicines and Supplements
Please list any medications/drugs you have taken in the past 6 months and why: (prescription and non-prescription)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Please list all nutritional supplements, vitamins, homeopathic remedies you presently take and why:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Past Health History
Please mark the following conditions you may have had or have now (X have had, √ have now):
□
□
□
□
□
□
Alcoholism
Allergy
Anemia
Arteriosclerosis
Arthritis
Asthma
□
□
□
□
□
□
Back Pain
Cancer
Cold Sores
Constipation
Convulsions
Depression
□
□
□
□
□
□
Diabetes
Diarrhea
Eczema
Emphysema
Epilepsy
Gall Bladder
Problems
□
□
□
□
□
□
Gout
Headaches
Heart Attack
Heart Disease
High Blood
HIV (Aids)
Pressure
□
□
□
□
□
□
Irregular Periods
Low Blood Sugar
Malaria
Measles
Menstrual Cramps
Migraines
□
□
□
□
□
□
Miscarriage
Multiple Sclerosis
Mumps
Neck Pain
Nervousness
Neuritis
□
□
□
□
□
□
Pleurisy
Pneumonia
Polio
Rheumatic
Ringing in ears
Sinus
Fever
Problems
□
□
□
□
□
□
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Whooping
Cough
Other (please explain) ________________________________________________________________________________________
Is there anything else which may help to better understand you which has not been discussed?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_________________________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical