Medical History Form
The answers provided in this form are confidential and are used to gain information about your current symptoms and health concerns. Please answer all the questions that pertain to you as this will assist in most accurate interpretation of your results.
Full Name
First Name
Last Name
What is your age?
What is your weight?
What is your height?
What is your gender?
Please Select
Male
Female
N/A
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:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Check the Gastrointestinal Symptoms you are experiencing:
Indigestion
Excessive Belching
Bloating
Feeling Full after a meal
Feeling Food in Stomach long time after meal
Bad Breath
Loss of Appetite or Nausea
History of Anemia
Stomach pain, 1-4 hours after eating
Feeling hungry after eating
Heartburn from spicy, fatty, citrus, alcohol or caffeine
Stomach discomfort to emotions, thoughts or smell of food
Heartburn aggravated by lying down or bending forward
Difficulty or pain when swallowing
Black tarry stools
Vomiting blood or vomit looks like coffee grounds
Check the Small Intestine/Pancreas symptoms you are experiencing:
Indigestion, bloating many hours after eating
Abdominal pain or aches
Nausea and vomiting
Excessive passage of gas
Diarrhea (loose, watery or frequent stools)
Constipation (straining, hard or dry stool)
Alternating constipation and diarrhea
Undigested food in stool
Stools greasy, smelly, or stick toilet bowl
Certain foods worsen abdominal symptoms
Dry flaky skin and dry brittle hair
Difficulty gaining weight
Check the Liver/Gallbladder symptoms you are experiencing:
Upper abdominal pain under ribs
Bloating or fullness after eating
Excessive belching or gas
Fatty foods cause indigestion/nausea
Loss of appetite
Unexplained itchy skin
Dark urine or yellow in and around eyes
Pale clay coloured stools
Fatigue, Sickness or weakness
Fluid Retention/Edema
Easy bruising/bleeding (gums)
Loss or thinning of hair
Red skin specifically palms
Check the Colon symptoms you are experiencing:
Lower abdominal pain/spasms and/or cramps
Relief of abdominal pain by passing gas /stool
Narrow stools
Mucus or pus in stool
Red blood with bowel movement
Rectal pain or cramps
Anal itching
Sensation of incomplete emptying of bowel
Check the Low Immunity symptoms you are experiencing:
Frequent colds/flu
Bladder /skin infections
Ears always draining
Nasal congestion /discharge
Sore throat
Neck, armpit or groin swelling
Cough with mucus
Cold sores
Wounds heal slowly
Excessive loss of hair
Inflamed or bleeding gums, swollen red lips or tongue
Check the Allergy symptoms you are experiencing:
Migraines/ headache
Sensitivity to light
Dark circles under eyes
Itching: eyes, ears, throat, nose, skin
Rashes or Ezcema
Clear watery discharge from eyes/nose
Sneezing, coughing or wheezing
Irritability/ Fatigue
Certain foods worsen symptoms or cause palpitations
Check the Cardiovascular symptoms you are experiencing:
Excessive Fatigue
Longer recovery after exercise
Low exercise tolerance
Shortness of breath with exertion
Dizziness, spots before eyes, ringing ears
Difficulty focusing/ poor memory
Yellowing of eyes/skin
Pale eyelids, lips, gums, nails
Red sore tongue
Sores in corner of mouth
Easy Bruising or bleeding
Check the Blood Pressure symptoms you are experiencing:
Nose bleeds
Redness in face
Blurred vision/ringing ears
History of High Blood Pressure
Check the Heart symptoms you are experiencing:
Palpitations
Dizziness
Pain/Heaviness in chest
Heartburn, heavy sensation that moves to neck, jaw, left shoulder, arm
Pallor or sweating with chest discomfort
Unusual digestion with chest discomfort
Shortness of breath laying flat in bed or sudden shortness of breath in middle of night
Wheezing or dry cough
Veins on neck prominent
Swelling in feet, ankles or legs
History of high blood cholestrol
Check the Circulatory Systems you are experiencing:
Poor Circulation in extremities, coldness, numbness or prickling sensations in hands and feet
Ulcers on feet or legs
Muscle pain in calves or thighs when walking
Faints or falls with unknown cause
Brief periods of difficulty speaking, swallowing or understanding speech or written word
Brief periods of loss of whole or part of vision, double vision, impaired coordination or areas of numbness
Check the Glucose Intolerance symptoms you are experiencing:
Fatigue and weakness/shaky
Mild headache
Sweating or palpitations
Feeling lightheaded or faint
Difficulty focusing, poor memory, confusion
Agitation, irritablility
Check the Hyperglycemia Symptoms you are experiencing:
Excessive, frequent urination
Increased thirst and appetite
Blurred vision, failing eyesight
Fatigue, drowsiness
Dizziness when standing from sitting position
Unintentional weight loss/weight gain
Recurring infections (bladder/skin)
Ulcer/Sores on legs or feet
Slow wound healing
Diagnosis of diabetes
Check the Kidney/Bladder Symptoms you are experiencing:
Fluid retention throughout body
Bloody, cloudy/smelly or darkened urine
Low back pain
Incontinence
Excessive urination and/or at night
Infrequent urination
Frequent urination
Grey cast to skin
Urgency of urination
Severe 1 sided lower back or groin pain associated with restlessness
History of kidney stones
Check the Prostate/Hormone balance symptoms you are experiencing (MEN):
Difficulty urinating
Painful testicles
Testicles uneven in size, texture or hardness
Loss or thinning of body or facial hair, or slow hair growth
Ejaculation causes pain
Blood in semen
Low libido
Severe 1 sided lower back or groin pain associated with restlessness
Inflammation of penis or unusual discharge from penis
Development of breast or nipple tenderness
Check the PMS/Menstrual/Hormone balance symptoms you are experiencing:
Insomnia
Abdominal Bloating
Breast tenderness, swelling/lumps
Feeling depressed, teary or sensitive
Diarrhea or constipation
Headaches or migraines
Food cravings or binge eating
Lower Abdominal and/or Back pain
Fluid retention or weight gain
Clumsiness
Irregular periods
Bleeding between periods
Painful intercourse during menstruation
Pelvic and/or rectal pressure around period
Light flow
Heavy flow
No period
Dry skin, hair or vagina
Low libido
Mood swings, irritability, depression
Nervousness / Anxiety
Night sweats
Difficulty focusing, poor memory, confusion
Thinning of armpit and pubic hair
Increased hair growth on upper lip
Breasts reducing in size and starting to sag
Engorged breasts
Acne/oily skin
Miscarriage
Vaginal discharge: excessive, smelly/coloured
Breast lumps, or a change in breast size or shape
Nipple discharge, change in appearance
Swelling under armpit
Check the Musculoskeletal Symptoms you are experiencing:
Localized bone pain
Bone deformity or swelling
Shins hurt during/after excercise
Low back or hip
Walking difficulties/limp
Hearing loss/headaches/ringing in ears
Diagnosis of osteoporosis
Abnormal spinal curvature
Bowed legs
Muscle aches and pains
Muscle stiffness tension
Fatigue
Difficulty sleeping
Muscle cramps/twitch/spasms/tremble
Restless legs
Muscle weakness
Muscle loss and wasting
Tender, red, swollen and stiff joints
Dry mouth, dry, painful eyes
Creaking (noisy) joints
Shooting, aching, tingling pain down the back of leg
More than one joint pain
Limited range of motion
Difficulty standing up from seated position
Impaired mobility and function
Difficulty chewing or opening mouth
Numbness, prickling, tinging, in neck, shoulders/arms
Red, painless skin lumps on elbows/knees/toes
Check the Brain and Nervous System symptoms you are experiencing:
Headache
Lightheadedness, fainting
Ringing or buzzing in ears
Trembling Hands
Weakness
Numbness, pins & needles
Unsteady on feet
Easily fatigued
Poor hand coordination
Convulsions, seizures
Drooping eyelids
Impaired hearing, eyesight, sense of touch, smell or taste
Slow or slurred speech
Incontinence
Check off your Stress History symptoms:
Divorce
Separation
Marriage
Death of loved one
Loss of work
Bankruptcy or change in finances
Moving
Violations from law
Have overactive mind/worry a lot
Work/Live Stressful environment
Suffer constant pain/discomfort
Eat chocolate/drink caffeine in evening
Difficulty falling/staying asleep
Eat after 8 pm
Find it difficulty to keep still or fidgety
Short attention span
Difficult to relax
Learning difficulties
Food Allergies
Mental Confusion/sluggishness
Check off your Respiratory symptoms you are experiencing:
Shortness of breath/hard to breathe
Wheezing
Shallow Breathing
Cough/dry moist
Thick yellow, greenish or brown sputum
Blood in sputum
Frothy sputum
Noisy rattling sounds when breathing
Pain in chest
Bad breath or sputum smells offensive
Loud snoring
Cold always "go to the chest"
Bluish nails or lips
Check off your Hair, Skin, & Nails symptoms you are experiencing:
Acne
Psoriasis
Eczema/dermatitis
Warts
Tinea
Dandruff
Rashes
Areas of increased pigmentation
Areas of decreased pigmentation
Unusual or changing moles
Areas of unexplained redness
Undiagnosed skin lumps/bumps
Discoloured nails
PItted nails
Weat/brittle nails
Thickened nails
Detoxification: Do you have a sensitivity to the following? Please check
Preservatives (Sodium/Potassium Benzoate)
Tyramine (Red wine, cheese, bananas, chocolate)
Caffeine
Small amounts of alcohol
Do you have a history of exposure to chemicals: herbicides/pesticides/organic solvents
Chemicals: fragrances, exhaust fumes, cigarette smoke, strong odours
How much Alcohol do you drink per week? Please click
0
1-3
4-7
7 or more
How much Coffee or Caffeinated drinks do you consume per day? Please click
0
1-2
3-4
4 or more
How much do you smoke per day? Please click
0
1-8
9-16
16 or more
If not smoking, have you quit within the last year? Please click
Yes
No
Are you currently taking any medication or herbal products? Please click
Yes
No
Please list them.
Do you have any medication allergies? Please click
Yes
No
Not Sure
Please list them.
Do you use any kind of illegal drugs or have you ever used them? Please select
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
General Health History
Frequency of Exercise (Please click)
Never
Occasionally 1-2 times per week
Moderately 3-5 times per week
Frequently/Daily
Vegetarian (Please check)
Yes
No
Planning to have a baby in next 6 months (Please check)
Yes
No
High Risk Symptoms (check all that apply)
Unexplained weight loss
Night sweats mild
Night sweat moderately
Night sweat frequently
Lumps breast/armpit/skin
Fevers mild
Fevers moderately
Fevers frequently
Reduced appetite
Severe fatigue
Pregnant or Breastfeeding (please check)
Yes
No
Do you diet often (Please check)
Yes
No
Medications taken in last 6 months (check all that apply)
Asthma/Inhalers
Insulin
Steroids e.g. Cortisone
Anti-inflammatories
Paracetamol
High Blood Pressure
Statins
Heart
Thyroid
Antihistamines
Antacids
Antibiotics
Antidepressants
Antipsychotics
Relaxants/sleeping tablets
Hormone/Oral Contraceptives
Chemotherapy
Please list any health issue in the past/operation etc...?
List your major health concerns at present.
Family History: diabetes, cardiovascular, cancer or any other illness.
Thank you for taking the time to complete this questionnaire.
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