Health History Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Occupation
Emergency contact person name
Emergency contact person phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Health Questions
Any broken bones ever?
Yes
No
If yes, explain:
Any sprains or strains ever
Yes
No
If yes, explain:
Are you using a cane or crutch?
Yes
No
If yes, explain:
Are you stable and strong on your feet?
Yes
No
If yes, explain:
Have you been hospitalized due to injury?
Yes
No
If yes, explain:
Do you have any allergies?
Yes
No
If yes, list allergies:
Are you taking any medications right now?
Yes
No
If yes, list medications:
Do you feel any pain or discomfort in your body?
Yes
No
If yes, how long?
Where do you feel the pain, what part of the body?
How would you describe the pain:
Burning
Aching
Numbness
Pins and needles
Hot
Other
Accidents, Injuries, Surgeries, PTSD, Trauma
Review Systems Health
Eyes
ears, those throat.
Normal
Not Normal
Musculoskeletal
(mobility)
Normal
Not Normal
Skin
-rashes, irritations.
Normal
Not Normal
Circulatory
skin, edema.
Normal
Not Normal
Neurovascular
Pain, seizures, sensations
Normal
Not Normal
Respiratory
shortness of breath
Normal
Not Normal
Dental Dentures
Normal
Not Normal
Mental Emotional
systems thoughts, beliefs
Normal
Not Normal
Nutrition
diet weight change swallowing
Normal
Not Normal
Elimination
Constipation, incontinence
Normal
Not Normal
Family History - illness.
Asthma
Diabetes
Cardiovascular Disease
Hypertension
Mental/Emotional problems
Cancer
Tuberculosis
Other
What does health and wellness feel/look like to you?
Do you feel like you are close to it, or further away?
Are you open to making changes to have the life you say you want to have?
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: