Health History Questionnaire Page 2
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4Birth History (when you or your child/children were born that caused significant trauma to you such as prolonged
labor, forceps delivery, etc.):
Allergies (drugs, chemicals, foods):
Family Medical History:
Diabetes
Cancer
High Blood Pressure
Heart Disease
Stroke
Seizures
Asthma Allergies
Other:
Medications taken within the last two months (vitamins, drugs, herbs, etc.):
Occupational Stress (chemical, physical, psychological, etc.):
Do you have a regular exercise program?
If so, please describe:
Have you ever been on a restricted diet?
If so, what kind?
Please describe your average daily diet:
Morning:
Afternoon:
Evening:
Do you smoke?
If so, how many packs a day?
How much coffee, tea, or soda do you drink per week?
How much alcohol do you drink per week?
Please describe any use of drugs for non-medical purposes:
Indicate painful or distressed areas:
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Parent category: Life