New Client Medical History Form
INITIAL CONSULTATION
Name
First Name
Last Name
Gender
Age
What is your main reason for your consultation today?
Allergies? If yes, please list. If no, put N/A.
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Please list any medications you are taking currently, if any.
Do you currently suffer from any of these conditions? Check all that apply.
ADD/ADHD
Alcoholism/Drug abuse
Asthma
Autoimmune
Cancer
Depression/Anxiety/Bipolar/Suicidal
Diabetes
Digestive Disorders (Celiac Disease, Gastric Reflux, etc)
Emphysema (COPD)
Epilepsy
Heart Disease
Hepatitis (please indicate which type in comment below)
High Blood Pressure (hypertension)
High Cholesterol
HIV/AIDs
Hives, Skin Rash, Hay Fever
Hormone Deficiency
Hyperthyroidism/Thyroid Disease
Insomnia
Liver Disease
Low Blood Pressure
Migraine Headaches
Osteoarthritis
Osteoporosis/Osteopenia
Renal (kidney) Disease
Rheumatoid Arthritis
STI/STD
Stroke
Other (indicate in comment below)
Please add any additional comments about your condition(s) from above, if any. (For example, if you have an Autoimmune Disorder, be more specific such as lupus, multiple sclerosis, etc.)
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Are you presently being treated for any other illness? If yes, please indicate down below.
Are you aware of any changes in your health in the last 24 hours? (i.e, fever, chills, new cough, etc)
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Do you smoke or take tobacco/tobacco products?
Yes
No
Please list all medications, supplements, and/or vitamins, if any.
Do you drink alcohol?
Yes
No
How many drinks do you estimate you consume per week?
0-2
3-6
greater than 6
Do you use marijuana or recreational drugs?
Yes
No
Do you exercise regularly?
Yes
No
How many hours, on average, do you sleep at night (or during the day, if working night shift)?
Have you traveled out of the country in the last 30 days?
Yes
No
If yes, where?
How would you rate your diet?
Excellent
Good
Fair
Poor
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REVIEW OF SYSTEMS
Please check all that apply.
CONSTITUTION
Activity change
Appetite change
Chills
Diaphoresis (Excessive sweating)
Fatigue
Fever
Unexpected weight change
HEAD, EAR, NOSE & THROAT
Congestion
Dental problem
Drooling
Ear discharge
Ear pain
Facial swelling
Hearing loss
Mouth sores
Nosebleeds
Postnasal drip
Rhinorrhea (runny nose)
Sinus pressure
Sneezing
Tinnitus
Trouble swallowing
Voice change
EYES
Eye discharge
Eye itching
Eye pain
Photophobia (sensitivity to light)
RESPIRATORY
Apnea
Chest tightness
Choking
Cough
Shortness of breath
Stridor (high pitched sound when breathing in)
Wheezing
CARDIOVASCULAR
Chest pain
Leg swelling
Palpitations
GASTROINTESTINAL
Abdominal distention
Abdominal pain
Anal bleeding
Blood in stool
Constipation
Diarrhea
Nausea
Rectal pain
Vomiting
ENDOCRINE
Cold intolerance
Heat intolerance
Polydipsia (excessive thirst)
Polyphagia (extreme hunger)
Polyuria (frequent urination)
GENITOURINARY
Difficulty urinating
Dysuria (painful or difficult urination)
Enuresis (involuntary urination)
Flank pain
Frequency
Genital sore
Hematuria (blood in urine)
Penile discharge
Penile pain
Penile swelling
Scrotal swelling
Testicular pain
Urgency
Urine decreased
MUSCULAR
Arthralgias (joint pain)
Back pain
Gait problems (walking problems)
Joint swelling
SKIN
Color change
Pallor (unhealthy pale)
Rash
Wound
ALLERGY/IMMUNO
Environmental allergies
Food allergies
Immunocompromised
NEUROLOGICAL
Dizziness
Facial asymmetry
Headaches
Light-headedness
Numbness
Seizures
Speech difficulty
Syncope
Tremors
Weakness
HEMATOLOGIC
Adenopathy (large or swollen lymph nodes)
Bruises/bleeds easily
PSYCHIATRIC
Agitation
Behavior problem
Confusion
Decreased concentration
Dysphoric mood
Hallucinations
Hyperactive
Nervous/anxious
Self injury
Sleep disturbance
Suicidal ideas
Submit
Should be Empty: