Medical History Form
ChoiceSmart Edu - Functional pshychologist
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Email Address
example@example.com
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Thyroid
Other
Please list them.
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Please list them.
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
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?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Over the last two weeks, how many of the following problems have you been bothered ?
Having a sense of impending danger, panic or doom
Trouble relaxing
Feeling nervous, anxious, or on edge
Being so restless that it is hard to sit still
Not being able to stop or control worrying
Becoming easily annoyed or irritable
Worrying too much about different things
. Feeling afraid, as if something awfulmight happen
Having an increased heart rate
Breathing rapidly (hyperventilation)
Sweating
Trembling
Feeling weak or tired
Having trouble sleeping
Trouble concentrating or thinking about anything other than the present worry
Experiencing gastrointestinal (GI) problems
Having the urge to avoid things that trigger anxiety
Other
Plaese list them
All questions contained in this questionnaire are optional and will bekept strictly confidential. Check what correspond to you:
Doing exercise
Have constipation
Have a diet
Have often diareea
Have menstrual tension, pain, bloating, irritability, or othersymptoms at or around time of period
Slow movements and thoughts
Any urinary tract, bladder, or kidney infections within the last year
Hair loss
Any problems with control of urination
A puffy-looking face
Any hot flashes or sweating at night
A low-pitched and hoarse voice
Experienced any recent breast tenderness, lumps, or nipple discharge
Having trouble sleeping
If you have any kind of pain please give more details in other .
Thinnedor partly missing eyebrows
You have weightgain
A slow heart rate
A fast heart rate
Sensitivity to heat
Sensitivity to cold
Muscle weakness
Other
Plaese list them
Tell me your weakness and your strenght.
Tell me your full story. Describe yourself
What you believe can be the root cause of your actual condition
Signature
What are you eat and drink during one day
Submit
Should be Empty: