We hope you will answer the questions on this medical history form as thoughtfully as possible. Many of the questions that follow may not seem directly related to your main complaint or reason for seeking care. However, the answers to these questions, as well as the information you provide in the office, will determine the individualized approach taken to begin your treatment. Please consider this an opportunity to write anything you think may be pertinent to your health that you may not have spoken with any other provider in the past. ALL THE INFORMATION IN THIS QUESTIONNAIRE IS CONFIDENTIAL BY LAW.

 

 

Context of Care

Your Medical History - Please check all that apply

General States of Health - Please check all that apply

Head, Ears, Eyes, Nose, and Throat - Please check all that apply

Skin, Hair & Nails - Please check all that apply

Respiratory & Cardiac- Please check all that apply

Gastrointestinal- Please check all that apply

Genitourinary- Please check all that apply

Menstrual/Menopausal- Please check all that apply

Please check all that apply:

Endocrine- Please check all that apply

Musculoskeletal and Neurological - Please check all that apply

Psychosocial - Please check all that apply

3 Day Diet History

Please record breakfast, lunch, dinner, and snacks for any 3 days prior to your appointment. Please include drinks. It is not necessary to write amounts of each item. (eg. Simply write peas. Not necessary to write 1/2 cup of peas)

I hereby certify that the above information is true and accurate to the best of my knowledge.