nelsonhealingcenter.org - Health History

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HEALTH HISTORY
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Phone Number
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

SinglePartnerMarriedSeparatedDivorcedWidow(er)
Are you recovering from a cold or flu?
Are you pregnant?
Reason of office visit:
Date begin:

MonthDayYear
Date
Date of last physical exam

MonthDayYear
Date
Practitioner name
Practitioner phone number
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):

Diet modificationFastingVitamins/mineralsHerbsHomeopathyChiropracticAcupunctureConventional drugsOther
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:

	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):

	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

UnderweightOverweightJust right
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)?
Corrective lensesDenturesHearing aidMedical devices/prosthetics/implants
Describe
Recent changes in your ability to

SeeHearTasteSmellfeel hot/cold sensationsmove around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers
Strong like for any of the following flavors:

SourBitterSweetRich/fattySpicy/pungentSalty
Strong dislike for any one of the following flavors:

SourBitterSweetRich/fattySpicy/pungentSalty
Do you:

Prefer warmth (i.e., food, drinks, weather, etc.)Prefer cold (i.e., food, drinks, weather, etc.)No preference
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

7 a.m.- 9 a.m.9 a.m. - 11 a.m.11a.m.- 1 p.m.1 p.m. - 3 p.m.3 p.m.- 5 p.m.5 p.m.- 7 p.m7 p.m.- 9 p.m9 p.m.- 11 p.m.11 p.m.- 1 a.m1 a.m. - 3 a.m3 a.m. - 5 a.m.5 a.m.- 7a.m.
Time of day you feel the worst or your symptoms are aggravated:

7 a.m.- 9 a.m.9 a.m. - 11 a.m.11a.m.- 1 p.m.1 p.m. - 3 p.m.3 p.m.- 5 p.m.5 p.m.- 7 p.m7 p.m.- 9 p.m9 p.m.- 11 p.m.11 p.m.- 1 a.m1 a.m. - 3 a.m3 a.m. - 5 a.m.5 a.m.- 7a.m.
Do you experience any of these general symptoms EVERY DAY?

Debilitating fatigueDepressionDisinterest in sexDisinterest in eatingShortness of breathPanic attacksHeadachesDizzinessInsomniaNauseaVomitingDiarrheaConstipationFecal incontinenceUrinary incontinenceLow grade feverChronic pain/inflammationBleedingDischargeItching/rash
Medical History

ArthritisAllergies/hay feverAsthmaAlcoholismAlzheimer's diseaseAutoimmune diseaseBlood pressure problemsBronchitisCancerChronic fatigue syndromeCarpal tunnel syndromeCholesterol, elevatedCirculatory problemsColitisDental problemsDepressionDiabetesDiverticular diseaseDrug addictionEating disorderEpilepsyEmphysemaEyes, ears, nose, throat problemsEnvironmental sensitivitiesFibromyalgiaFood intoleranceGastroesophageal reflux diseaseGenetic disorderGlaucomaGoutHeart diseaseInfection, chronicInflammatory bowel diseaseIrritable bowel syndromeKidney or Madder diseaseLearning disabilitiesLiver or gallbladder disease (stones)Mental illnessMental retardationMigraine headachesNeurological problems (Parkinson's, paralysis)Sinus problemsStrokeThyroid troubleObesityOsteoporosisPneumoniaSexually transmitted diseaseSeasonal affective disorderSkin problemsTuberculosisUlcerUrinary tract infectionVaricose veinsOther
Medical (Men)

Benign prostatic hyperplasia (BPH)Prostate cancerDecreased sex driveInfertilitySexually transmitted diseaseOther
Medical (Women)

Menstrual irregularitiesEndometriosisInfertilityFibrocystic breastsFibroids/ovarian cystsPremenstrual syndrome (PMS)Breast cancerPelvic inflammatory diseaseVaginal infectionsDecreased sex driveSexually transmitted diseaseSurgical menopauseMenopauseOther
Age of first period
Date of last gynecological exam

MonthDayYear
Date
Mammogram
PAP
Form of birth control
# of children
# of pregnancies
C-section
Date of last menstrual cycle

MonthDayYear
Date
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)

ArthritisAsthmaAlcoholismAlzheimer's diseaseCancerDepressionDiabetesDrug AdditionEating disorderGlaucomaHeart diseaseInfertilityLearning disabilitiesMental illnessMental retardationMigraine headachesNeurological disorders (Parkinson's, paralysis)ObesityOsteoporosisStrokeSuicideOther
Health Habits

Tobacco
Cigarettes: #/day
Cigars: #/day
Alcohol
Wine: #glasses/d or wk
Liquor: #ounces/d or wk
Beer #glasses/d or wk
Caffeine
Coffee: #6 oz cups/d
Tea: #6 oz cups/d
Soda w/caffeine: #cans/d
Water: #glasses/d
Other sources
Exercise

5-7 days per week3-4 days per week1-2 days per week45 minutes or more duration per workout30-45 minutes duration per workoutLess than 30 minutesWalkRun, jog, jump ropeWeight liftSwimBoxYoga
Nutrition & Diet

Mixed food diet (animal and vegetable sources)VegetarianVeganSalt restrictionFat restrictionStarch/carbohydrate restrictionThe zone DietTotal calorie restriction
Specific food restrictions:

dairywheateggsSoyCornall glutenOther
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

Skip breakfastTwo meals/dayOne meal/dayGraze (small frequent meals)Food rotationEat constantly whether hungry or notGenerally eat on the runAdd salt to food
Current Supplements

Multivitamin/mineralVitamin CVitamin EEPA/DHAEvening Primrose/GLAMagnesiumZincFriendly flora (acidophilus)Digestive enzymesAmino acidsCoQ10Antioxidants (e.g., lutein, resveratrol, etc.)Herbs-teasHerbs-extractsChinese herbsAyurvedic herbsHomeopathyBach flowersProtein shakesSuperfoods (e.g., bee pollen, phylonutrient blends)Liquid meals
Calcium, source
Minerals, describe
Other
Would you like to:

Have more energyBe strongerHave more enduranceIncrease your sex driveBe thinnerBe more muscularImprove your complexionHave stronger nailHave healthier hairBe less moodyBe less depressedBe less indecisiveFeel more motivatedBe more organizedThink more clearly and be more focusedImprove memoryDo better on tests in schoolNot be dependent on over-the-counter medications like aspirin, ibuprofen, anti-histamines, sleeping aids, etc.Stop using laxatives or stool softenersBe free of painSleep betterHave agreeable breathHave agreeable body odorHave stronger teethGet less colds and flusGet rid of your allergiesReduce your risk of inherited disease tendencies (e.g., cancer, heart disease, etc.)
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