nelsonhealingcenter.org - Health History

New Patient Form
HEALTH HISTORY
Today's Date

MonthDayYear
Date
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
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
Format: (000) 000-0000.
Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis). Please state outcome for each procedure:
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:

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):
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
SeeHearTasteSmellfeel hot/cold sensationsmove around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers
SourBitterSweetRich/fattySpicy/pungentSalty
SourBitterSweetRich/fattySpicy/pungentSalty
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?
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.
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.
Debilitating fatigueDepressionDisinterest in sexDisinterest in eatingShortness of breathPanic attacksHeadachesDizzinessInsomniaNauseaVomitingDiarrheaConstipationFecal incontinenceUrinary incontinenceLow grade feverChronic pain/inflammationBleedingDischargeItching/rash
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
Benign prostatic hyperplasia (BPH)Prostate cancerDecreased sex driveInfertilitySexually transmitted diseaseOther
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)
ArthritisAsthmaAlcoholismAlzheimer's diseaseCancerDepressionDiabetesDrug AdditionEating disorderGlaucomaHeart diseaseInfertilityLearning disabilitiesMental illnessMental retardationMigraine headachesNeurological disorders (Parkinson's, paralysis)ObesityOsteoporosisStrokeSuicideOther
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
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
Mixed food diet (animal and vegetable sources)VegetarianVeganSalt restrictionFat restrictionStarch/carbohydrate restrictionThe zone DietTotal calorie restriction
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
Skip breakfastTwo meals/dayOne meal/dayGraze (small frequent meals)Food rotationEat constantly whether hungry or notGenerally eat on the runAdd salt to food
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
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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