New Patient Health History Form Page 3
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7Medicine In Balance
New Patient Health History Form
Health History
How many caffeine-containing drinks do you consume each day (including coffee, tea and soda)? ______
Do you currently smoke? Yes [ ] No [ ]
If Yes, how long does a pack last? __________
Number of years smoking? _________
Number of years since quitting?
__________
How many alcoholic drinks do you consume in a week?
____________
What type of alcohol do you drink? (beer, wine, liquor)
____________
Do you use any recreational drugs?
Yes [ ] No [ ]
If so, please list: ________________________________________________________________________________
Are you currently involved in an exercise program? Yes [ ] No [ ]
How many hours a week on average do you:
Perform vigorous exercise (e.g. brisk walking, jogging, biking, aerobics classes)
______
Perform strength training (e.g. weight machines or free weights)
______
Perform stretching exercise (e.g. yoga, tai chi, ballet, general stretches)
______
How long have you been doing your current routine? _______________
How many meals a day do you usually eat?
____________
snacks? _________
How many meals do you usually eat away from home each day? ___________
What is your current weight? _______ What is your current height? _________
Have you recently gained or lost weight? Gained [ ] Lost [ ] Stayed the same [ ]
Hardl y
So me
Nearly
Never
Eve r
time s
Alway s
Alway s
Do you feel in control of your eating habits?
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Do you feel in control of your lifestyle?
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Do you find yourself obsessing about food, weight, body
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image?
Do you have periods of low energy, mood swings, and
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irritability?
Are you satisfied with the quality and quantity of your sleep?
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Please list any herbals, supplements or vitamins you are taking:___________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________
Do you have a spiritual/ religious practice? Please describe: ______________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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