Health History Form

Health History Form

Long Form
Date

Month Day Year
Date
Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Birthdate
Physician
Reason for last visit to physician
Enter the message as it's shown *
Height and Weight
Most you have weighted as an adult
Include year
Least you have weighted as an adult
Include year
Occupation
Highest level of education
Marital status
Level of stress you experience (1 - 10)
What are your top three health concerns?
How long have you had these concerns?
Are you willing to make lifestyle changes to address these concerns?
What other health conditions have you had in the past?
Include year
Please describe your parents' current health or cause of death.
Please describe siblings and children's health.
Check conditions which have occurred in your blood relatives

Diabetes Cancer Heart disease Stroke High blood pressure Depression/anxiety
Describe a typical breakfast
Describe a typical lunch
Describe a typical dinner
List any foods you crave.
List any food sensitivities.
Do you use, or have you used alcohol, coffee, tobacco, recreational drugs?
If so, include frequency and if current or past.
List exercise, include frequency per week.
List all medications.
List all herbs and supplements.
Include dose and frequency
Upper GI symptoms

Sometimes nauseated in evenings Dry mouth Occasional foul burps Quickly feel full Seldom eat breakfast Indigestion Frequent mouth sores Bad morning breath Bitter taste in morning Strong, demanding hunger Frequent poor appetite
Lower GI Symptoms

Constipation with gas Frequent constipation Constipation with painful BM Constipation with hemorrhoids Mucous in stools Undigested food in stools Diarrhea Loose stools with gas Tongue often coated
Liver

Seasonal allergies or asthma Crave sweets Trouble digesting fats Acne on face and buttocks History of working with solvents Frequent minor illnesses Moist, sometimes oil skin Hives from food or drugs Crave protein and fats Frequent use of alcohol (5+ serving/week) Skin irritations - psoriasis, eczema, dermatitis
Kidneys

Standing quickly causes dizziness Standing quickly causes roaring ears Frequent flushing/blushing Moderately low blood pressure Moderately high blood pressure Urine always light colored Wake up at night to urinate Frequent water retention Urine usually dark Frequent thirst Craving for salt
Lower Urinary Tract

Frequent urination, small amounts Occasional post-urination dribble Demanding need to urinate Infrequent urination, copious Frequent bladder infections Mucous in urine Dull ache after urination
Reproductive System

Dry skin, cold hands and feet Oily skin, facial acne Sweat freely with strong scent
Women

Cycle longer than 28 days Miss occasional periods Menses slow to start with cramping Constipation before menses, followed by loose stools Class II Pap smear History of PID, cervicitis Miscarriages Unable to take birth control pill due to side effects Take birth control pill Cycle less than 28 days Water retention prior to menses Menstruation longer than 5 days PMS - increased hunger PMS - Breasts tender PMS - Heart palpitations Hot flashes
Respiratory System

Shortness of breath when standing or walking Sometimes wake up choking or gasping for breath Frequent chest colds Frequent coughing with mucus Occasional hyperventilation Rapid, shallow breathing
Cardiovascular System

Fast, light pulse Slow, strong pulse Occasional dizziness Hands cold, clammy or dry Hands warm and sweaty Warm-bodied Cold-bodied Hypertension not responsive to diuretics Hypertension, responsive to diuretics
Lymphatic System

Recuperate slowly if ill Recuperate quickly if ill Injuries heal slowly Injuries heal quickly Eczema, dermatitis Asthma or seasonal allergies Arthritis
Skin

Skin eruptions deep Skin eruptions superficial Skin on trunk is dry Oily scalp or hair Dry scalp or hair Cracks, fissures on heels, elbows, feet
Endocrine System

Dry, brittle hair Loss of head hair Fatigue Weight gain Decreased libido Lack of hair on legs Insomnia

Please mark severity of symptoms you experience.

Mild

Moderate

Severe

Awaken at night, can't fall back to sleep

Difficulty falling asleep

Difficulty waking in morning

Bad dreams

Restless sleep

Blurred vision

Eyes often red or inflamed

Face and/or eyes puffy

Bruise easily

Difficulty gaining weight

Difficulty losing weight

Sudden weight loss

Extreme fatigue

Depressed

Highly emotional

Cry easily without apparent cause

Headaches

Heart palpitations when hungry

Heart palpitations after eating

Impaired hearing

Earaches

Ears itchy

Ringing in ears

Numbness or tingling in legs

Numbness or tingling in arms

Muscle cramps

Nails brittle

Low back pain

Frequent nose bleeds

Facial twitches

Sensitive to cold weather

Sensitive to hot weather

Sensitive to humidity

Sexual desire increased

Sexual desire decreased

Frequent nasal congestion

Is there anything else you would like to mention?
Should be Empty:

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