Vreeland - FirstLine Therapy Patient Health History

FirstLine Therapy Patient’s Health History

(Confidential)
Today's date

MonthDayYear
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone

Area CodePhone Number
Occupation
Age
Height
Sex
Marital status (optional)
Are you recovering from a cold or flu?
Are you pregnant?
Reason for your visit
List current health problems for which you are being treated:
What types of therapies have you tried for these problems(s) or to improve your health overall?

Other
Do you experience any of these general symptoms on a regular basis?
Current medications (prescription or over-the-counter)
Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis):
Outcome
Major hospitalization, surgeries, injuries. Please list all procedures, complicatons (if any) and dates:
Indicate the level of stress you are experiencing on a scale of 1 to 10
Identify the major causes of stress (e.g., changes in job, residence or finances)
Do you consider yourself:
Your weight today
Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months?
Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) and/or life-threatening activities (e.g., firefighter, police officer, etc.)?
What are your current health goals?
Medical History
Other
Medical – Men
Other
Medical – Women
Other
Date of last GYN exam
Mammogram
PAP
Form of birth control
Number of children
Number of pregnancies
C-sections
Age of first period
Date of last menstrual cycle
Length of cycle
Interval of time between cycles
Any recent changes in normal menstrual flow (e.g., heavier, large clots, scanty)
Family Health History (Parents and Siblings)

Other
Health Habits
Cigarettes
Cigars
Wine
Liquor
Beer
Coffee
Tea
Soda with caffeine
Other sources of caffeine
Water consumption
Exercise
Amount you exercise
Duration of workouts
Walking
Run, jog, other aerobics
Weight lift
Stretch
Other
Nutrition and Diet
Food specific restrictions

Other
Eating Habits
Skip meals
Food Frequency
Fruits
Dark green or deep yellow/orange vegetables
Grains (unprocessed)
Beans, peas, legumes
Dairy, eggs
Meat, poultry, fish
Current Supplements

Other
Minerals - describe
I Would Like:
Energy, Vitality

Other
Body Composition

Other
Stress: Mental & Emotional

Other
Life Enrichment

Other
Should be Empty:

FirstLine Therapy Patient’s Health History