Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Gender
Please Select
Male
Female
Place of Birth
City/State or Town/Country if not in the US
Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
Genetic Background
Caucasian
African American
Hispanic
Asian
Mediterranean
Native American
Jewish
Northern European
Other
Education
High School
Under-graduate
Post-graduate
Some College
Other
Occupation/Job Title
Please list your wellness goals:
When was the last time you felt well?
Did something trigger your change in health?
How motivated are you to make changes to your health?
Patient Birth History:
Vaginal delivery
C-section
Full term
Premature
Breast-fed
Bottle fed
Blood type
A
B
AB
O
Rh+
Rh-
Unknown
Personal Medical History
Rows
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other
Personal Medical History cont.
Rows
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Herpes - genital
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Food allergies
Environmental allergies
Multiple chemical sensitivites
Latex allergy
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Please list any significant physical trauma you've experienced:
Please list emotional trauma you've experienced in your life:
Gynecological Hx cont.
Post partum depression
Toxemia
Gestational diabetes
Baby over 8 pounds
Gynecological Hx cont.
Rows
Present use
Past use
Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy
Gynecological Hx cont.
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
Menopausal patients
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
Men's history
Prostate enlargement
Prostate infection
Change in libido
Impotence
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Dental history
Silver Mercury filling
Gold fillings
Root canals
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
Medication history
Rows
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives
Family History
Rows
Mother
Father
Sibling
Children
Mat. Grandparent
Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease
Heading
Should be Empty: