• Health History and Medications

    Health History and Medications

    Form 1 of 2

  • Thank you for choosing Healing InSight!
    We're delighted to work with you to help you feel better, look younger and love life!

     

    Please thoughtfully answer these questions so we're able to develop an individualized diagnosis and treatment plan that's right for you!

     
  • Todays Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to join Healing InSight's email list?
  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Genetic Background:
  • Format: (000) 000-0000.
  • Do you have a Flex Spending Account (FSA)?
  • Do you have a Health Savings Account (HSA)?

  • If you would like receipts to submit for FSA or HSA reimbursement, please ask at your appointment!

     

     
     

  • Click 'Next' to continue. Click 'Save' at any time to save your progress and come back later.

  • Current Health Concerns

    Please list current and ongoing health concerns and their effect your life
  • Please describe the problem you are experiencing and the severity of the problem below. How does the problem effect your daily life?
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  • 0/100
  • 0/100
  • 0/100
  • 0/100
  • 0/100

  • Medications and Supplements

  • Current Medications (include prescription and over-the-counter)
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  • Vitamins, supplements and herbs
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  • Have medications or supplements ever caused unusual side effects or problems?
  • Blood type:

  • Allergies

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

  • HEALTH HISTORY

    MEDICAL HISTORY: ILLNESSES/CONDITION

  • Check YES = a condition you currently have or have had in the most recent 6 months

    Check PAST = a condition you've had in the past, longer than 6 months ago

     
  • Gastrointestinal
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  • Respiratory
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  • Cardiovascular
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  • Muskuloskeletal
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  • Skin
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  • Cancer
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  • Endrocrine/Metabolic
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  • Inflammatory/Immune
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  • Neurological/Emotional
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  • Urinary/Genital
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  • Diagnostic Tests: Type YES for the tests you've done, indicate the year performed and any significant findings.
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  • Birth/Childhood History

  • Were you born:
  • Were there any pregnancy or birth complications with your birth?
  • Childhood History: at what age were you introduced to the following?
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  • As a child, were there any foods that were avoided because they gave you symptoms?
  • Did you eat lots of sugar or candy as a child?
  • Timeline of Major Health/Life Events
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  • Have you used any of these regularly, or for a long time?
  • How many times have you taken antibiotics?
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  • Have you ever taken long term antibiotics?
  • How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?
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  • Symptom Review (within the last 6 months)

  • Mark YES for any mild or moderate symptoms you currently have or have had in the last 6 months.

    Mark SEVERE if it is a significant symptom.

  • Temperature
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  • Sweat and Thirst
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  • Energy
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  • Head
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  • Symptom Review (continued)

    Mark YES for any mild or moderate symptoms you currently have or have had in the last 6 months. Mark SEVERE if it is a significant symptom.
  • Senses
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  • Respiratory
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  • Cardiovascular
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  • Food Intolerances
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  • Symptom Review (continued)

    Mark YES for any mild or moderate symptoms you currently have or have had in the last 6 months. Mark SEVERE if it is a significant symptom.
  • Digestion
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  • Bowel Movements
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  • Symptom Review (continued)

    Mark YES for any mild or moderate symptoms you currently have or have had in the last 6 months. Mark SEVERE if it is a significant symptom.
  • Appetite/Cravings
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  • Urination
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  • Sleep
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  • Symptom Review (continued)

    Mark YES for any mild or moderate symptoms you currently have or have had in the last 6 months. Mark SEVERE if it is a significant symptom.
  • Musculoskeletal
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  • Mood/Emotions
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  • Nerves
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  • Symptom Review (continued)

    Mark YES for any mild or moderate symptoms you currently have or have had in the last 6 months. Mark SEVERE if it is a significant symptom.
  • Skin
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  • Nails
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  • You're doing great! You've completed Part 1 of the Health History Form!

    Please fill out out Part 2 of the Health History Form
    on the New Patient Information page of HealingInSightOnline.com.

     
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