Your Medical History

General Client Info Form
Client Name*

PrefixFirst NameMiddle NameLast NameSuffix
Gender*
Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Height (inches)*
Weight (pounds)*
Your E-Mail*
example@example.com
Reason for seeing the doctor:*
Client Medical History

(If you already answered any of these first questions on the Online Health Consent form, please enter "see Health Consent form" in any field below.)
Please list your Current Medications
Please list any drug allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Any Other illnesses:
Please list any Surgeries, Procedures, and Dates of Each
Healthy & Unhealthy Habits
Exercise

Never1-2 days weekly3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink at allI drink at least weeklyI drink at least monthlyI drink only on very special occasions at public eventsI would like to cut alcohol out of my life entirely
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Check all boxes of symptoms you are currently experiencing:
Include other comments regarding your Medical History
Please outline a typical day's Breakfast, Lunch, Dinner and Snack below. And your go-to beverage of choice.
One final important question: What is your main goal of this session?
Today's Date

MonthDayYear
Date
Should be Empty:

General Client Info Form

Client Medical History

Healthy & Unhealthy Habits