New Client History Form Web

New Client History Form
Name *

First Name Last Name
Date of Birth *

Month Day Year
Email
example@example.com
Select any conditions you currently have, or have ever had:

Diabetes High Blood Pressure Cholesterol Problems Heart Problems Stroke Seizures Sleep Apnea Insomnia Thyroid Problems Liver Problems Kidney Problems Osteoporosis Broken Bones Asthma Emphysema or COPD Anemia Stomach Ulcer Heartburn Arthritis HIV Infection Cancer Anxiety Panic Attacks Depression
Have you had any recent problems with any of the following?

Fatigue Weight Gain Weight Loss Heat Intolerance Cold Intolerance Poor Sleep Blurred Vision Double Vision Hoarseness Chest Pains Palpitations Shortness of Breath Cough Nausea Vomiting Diarrhea Constipation Frequent Urination Nighttime Urination Low Libido Hot Flashes Abnormal Periods (women) Poor Erections (men) Join Pain Muscle Aches/Pain Muscle Weakness Rash Easy Bruising Headache Numbness/Tingling Depression Anxious Falls
Please list all your medications, including any hormone medications, birth control, herbal medicines, supplements, vitamins, or over-the-counter medicine that you take on a regular basis. Please include your dosages (ie. 40mg, 20 units, etc) and how many times per day you take each.
Please list any other medical problems you have, or any other reason you see a doctor:
Please list any operations or hospitalizations you have had, including what year they occurred, if known:
When was your last influenza vaccine? Date
When was your last pneumonia vaccine?   Date
   Never had flu vaccine   Never had pneumonia vaccine
Please list any medication allergies or bad reactions to a medication that you have had:
What is your marital status? please type
How many children do you have? please type
What is your occupation? please type
Do you smoke?

Yes, every day Yes, some days Former Never
Do you drink alcohol?

Yes No
How many drinks per week? please enter a number
For your reference, one drink is 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of distilled spirits
Family History
Have any family members been diagnosed with the following?:

Diabetes High Blood Pressure High Cholesterol Heart Attack and/or Cardiac Bypass Surgery Stroke Cancer Thyroid Problems Kidney Stones Osteoporosis
Please enter as much information as you can about your family, including cause of death if applicable:
For Women Only:
How old were you when you had your first menstrual cycle? please type
Are your cycles regular? please type
What was the date your last menstrual cycle started? please type
Have you gone through menopause? please type
How many times have you been pregnant? please type
How many children do you have? please type
How many miscarriages have you had? please type
Should be Empty:

New Client History Form

Family History

For Women Only: