nelsonhealingcenter.org - Health History

New Patient Form
HEALTH HISTORY
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Age
Height
Sex
Number of Children
Martial status
Are you recovering from a cold or flu?
Are you pregnant?
Reason of office visit:
Date begin:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last physical exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Practitioner name
Practitioner phone number
Format: (000) 000-0000.
Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis). Please state outcome for each procedure:
What types of therapy have you tried for this problem(s):

Other
List current health problems for which you are being treated:
Current medications (prescription or over-the-counter):

Major Hospitalizations, Surgeries, Injuries: Please list all procedures, complications (if any) and dates:

Rows	Year	Surgery, Illness, Injury	Outcome
1.
2.

Select the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest):

Rows	1	2	3	4	5	6	7	8	9	10
*

Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems):
Do you consider yourself
Your weight today
Have you had an unintentional weight loss of 10 pounds or more in the last three months?
Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g., fireman, former, miner)?
Describe
Recent changes in your ability to
Strong like for any of the following flavors:
Strong dislike for any one of the following flavors:
Do you:
Is your sleep disturbed at the same time each night?
If yes, what time?
Time of day you feel the most energy or the least symptoms
Time of day you feel the worst or your symptoms are aggravated:
Do you experience any of these general symptoms EVERY DAY?
Medical History

Other
Medical (Men)

Other
Medical (Women)

Other
Age of first period
Date of last gynecological exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mammogram
PAP
Form of birth control
# of children
# of pregnancies
C-section
Date of last menstrual cycle

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Length of cycle days
Interval of time between cycles days
Any recent changes in normal menstrual flow (e.g., heavier, large clots, scanty)
Family Health History (Parents and Siblings)

Other
Health Habits
Cigarettes: #/day
Cigars: #/day
Wine: #glasses/d or wk
Liquor: #ounces/d or wk
Beer #glasses/d or wk
Coffee: #6 oz cups/d
Tea: #6 oz cups/d
Soda w/caffeine: #cans/d
Water: #glasses/d
Other sources
Exercise
Nutrition & Diet
Specific food restrictions:

Other
Food Frequency

Servings per day:
Fruits (citrus, melons, etc.)
Dark green or deep yellow or orange vegetables
Grains (unprocessed)
Beans, peas, legumes
Dairy, eggs
Meat, poultry, fish
Eating Habits
Current Supplements
Calcium, source
Minerals, describe
Other
Would you like to:
Should be Empty:

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