Health Assessment Form
Full Name
*
First Name
Last Name
What is your age?
*
Date of Birth
-
Month
-
Day
Year
Date
Medications
Yes
No
Smoking
No
Tobacco
Vaping
Other
Alcohol Consumption
Daily
Weekly
Monthly
Occasionally
Never
Exercise
Daily
Weekly
Monthly
Occasionally
Never
Surgery
Yes
No
Please list them
Scars
Yes
No
Please list them.
Sensitivities (allergies)
No
Seasonal
Food
Not Sure
Other
Please list them
Digestive Tract
Nausea or vomiting
Diarrhea
Constipation
Bloated feeling
Belching or passing gas
Heart burn
Intestinal/stomach pain
Other
Ears
Itchy ears
Earaches, ear infection
Drainage from ear
Ringing in ears
Hearing loss
Energy / Activity
Fatigue, sluggishness
Hyperactivity
Restlessness
Apathy, lethargy
Emotions
Mood swings
Anger, irritability
Anxiety, fear, nervousness
Depression
Stressed
Moody
Other
Head
Headaches
Faintness
Dizziness
Insomnia
Migraine
Sleep difficulty
Mind
Poor memory
Burnout
Difficulty making decisions
Poor concentration
Learning difficulties
Lightheaded
Heart
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Joints / Muscles
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness and tiredness
Musculoskeletal issues
Lungs
Chest congestion
Shortness of breath
Asthma, bronchitis
Difficult breathing
Mouth / Throat
Chronic coughing
Loss of voice
Sore Throat, hoarseness
Canker sores
Nose
Stuffy nose
Hay fever
Sneezing attack
Sinus problem
Excessive mucus formation
Skin
Acne
Hair loss
Excessive sweating
Hives, rushes, dry skin
Flushing or hot flushes
Echema
Other
Weight
Binge eating, drinking
Excessive weight
Water retention
Craving certain foods
Compulsive eating
Underweight
Gender specific
Female symptoms
Male symptoms
Female symptoms
Menopause
Night sweats
Polycystic ovaries
Lack of menstruation
Vaginal dryness
Increased fatigue
Hormonal imbalance
None
Other
Male symptoms
Soft difficult erection
Prostate enlargement
Difficulty urinating
Hormonal imbalance
None
Other
Other concerns
Family History
Yes
I don't know
Family History
Cancer
Heart disease
Hypertension
Obesity
Diabetes
Stroke
Autoimmune disease
Arthritis
Kidney disease
Thyroid problems
Anxiety
Depression
Asthma
Allergies
Eczema
ADHD
Autism
Dementia
Substance abuse
Psychiatric disorder
Irritable bowel syndrome
Celiac disease
Genetic disorders
Other
Did you have Covid19
Yes
No
Did you take Covid19 Vaccine
Yes
No
Covid Vaccine
Pfizer
Moderna
J&J
Novavax
Other
Additional Information
Today's date
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Month
-
Day
Year
Date
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