Medical History Form

Medical History Form
Full Name

First NameLast Name
Date of Birth Todays Date
What is your age?
What is your gender?
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Check the conditions that apply to you or any member of your immediate relatives:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Check the symptoms that you' re currently experiencing:*

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gain/lossWeight lossMusculoskeletalFatiguePoor sleepOther
Are you currently taking any medication or remedies?

YesNoMedicinesRemediesSupplements
Please list them.
Do you have any medication allergies?

YesNoNot Sure
Symptoms

include past symptoms, medical diagnosis,
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
I understand that this alternative approach to health and wellbeing is all about finding the cause of your symptoms and conditions. I will receive advice about the the solutions which are available and the directions on how to use them.

You may in addition be given advicve on diet, hydration, and good health habits.
Signature
Should be Empty:

Symptoms