Short Health History Form
for specific, acute situations
Street Address Line 2
State / Province
Postal / Zip Code
Reason for last visit to physician
Enter the message as it's shown
Height and Weight
Level of stress you experience (1 - 10)
What is your health concern?
List symptoms you are experiencing.
How long have you had this concern?
Have you seen a health care provider about this concern?
Have you received a diagnosis or had any testing done?
Please give details.
Have you had this concern in the past?
If so, when and how was it resolved?
List all medications.
List all herbs and supplements.
Include dose and frequency
Is there anything else you would like to mention?
Should be Empty:
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