• Health History and Medications

    Health History and Medications

    Thank you for choosing Healing InSight! We're delighted to work with you to help you feel better, look younger and love life!
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to join Healing InSight's email list and stay up-to-date on specials and holistic health topics?
  • Date of Birth
     / /
  • Martial Status:
  • Format: (000) 000-0000.
  • How did you hear about us?
  • Do you have a Flex Spending Account (FSA)?:
  • Do you have a Health Savings Account (HSA)?:
  • Have you been examined by a medical doctor for any of these health concerns?
  • Blood Type:
  • Have you ever been diagnosed with any of the following?:
  • Are you on a specialty diet?:

  • Health History

    Please mark any symptoms you currently have or have had in the past year.
  • Temperature
  • Perspiration/Thirst
  • Energy
  • Head
  • Senses
  • Mouth
  • Skin, Hair & Nails
  • Lungs & Heart
  • Apetite & Digestion

  • Health History (continued)

    Please mark any symptoms you currently have or have had in the past year.
  • Cravings
  • Bowel Movements
  • Urination
  • Sleep
  • Mental & Emotional
  • Diet & Lifestyle

  • MUSCULOSKELETAL & EXTREMITIES

  • Image field 55
  • Do you experience pain or numbness in any of the following areas?:
  • Do you have any of the following:

  • Menopause

  • Are you currently menopausal?
  • Do you currently experience any:

  • Gynecological Health History

  • General Gynecology

  • Reproductive History

  • Are you currently using birth control?
  • Are you trying to conceive?
  • Are you currently lactating?
  • Have you had any:

  • Regular cycle of days from period to period.

  • Irregular cycle: to

  • Can you tell when you ovulate?
  • Do you have spotting between periods?
  • PMS Symptoms:
  • After Menstruation
  • Image field 74

  • Medications and Supplements

  • Please list all medications (prescription and over-the-counter) and vitamins, supplements, and herbs you are currently taking.

  • MEDICATIONS

  • Today's Date
     - -
  • Rows

  • Vitamins, Supplements, & Herbs

  • Rows

  • Allergies:

  • Other:

  • Do you have a pacemaker?
  • Do you have a bleeding disorder?
  • Are you or could you be pregnant?

  • Cancellation and Payment Policies

    Payment is due on the day of the appointment. Receipts for insurance & healthcare/flex spending accounts reimbursements can be provided, please ask!

    Please give us 24 hours advance notice if you need to cancel an appointment. You may be charged if you cancel an appointment without 24 hours notice.

     

    Thank you for taking the time to fill out your health history so we can create the best treatment plan for you! We're looking forward to working with you!

     

    Note: Please also fill out the Policies and Informed Consent form so your paperwork is complete!

  •  
  • Should be Empty: