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Patient Information
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Place of Birth
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Marital Status
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Parent or Guardian (if patient is under 18)
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Occupation
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Children Name(s) & Age(s)
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Hobbies & Special Interests
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Type of Referral
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Name of Referrer:
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Primary Health Concern
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Health Concern #1
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When did you first notice this problem?
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What have you done so far to treat it?
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Additional Health Concerns
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3.
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Health Concern #2
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4.
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Allergies
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Food Allergies or Sensitivities
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Environmental Allergies (i.e. pollen, mold)
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Allergy to Medications / Herbs (i.e. sulfa drugs)
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Medical History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Comments
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Childhood illnesses
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Comments
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Injuries
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If yes, please briefly describe
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Current Doctors
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PCP ( Primary Care Practitioner)
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PCP Contact Information
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Date of last physical exam
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Additional doctors & health care providers (i.e. P.T., Chiro, M.D.)
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Family & Social History
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Use of the following substances?
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Alcohol (Specify type, frequency, quantity)
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Tobacco (Specify type, frequency, quantity)
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Coffee (Specify frequency, quantity)
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Soft Drinks (Specify type, frequency, quantity)
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Recreational Drugs (Specify type, frequency, and/or quantity)
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Medications, Herbs, Vitamins & Supplements
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Over The Counter Drugs
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Herbs, vitamins & supplements
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Medications
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Health & Self-Awareness Inquires
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Briefly describe how you feel about your life?
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What are your strengths?
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Any special ambitions or desires?
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How would you describe your energy levels?
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Describe your digestion.
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Do you fall asleep easily?
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How well do you sleep?
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Do you wake during the night?
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If yes, number of times
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How do you feel when upon waking?
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Do you exercise regularly?
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What type of exercise to you prefer?
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WOMEN: Please complete section
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Pregnant
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Due date if pregnant:
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Is your cycle regular?
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If no, last menstrual date.
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Cycle length (i.e. 28 days)
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Total days bleeding
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Blood volume
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Was there clotting?
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Was there cramping during menstrual cycle?
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Bleeding between cycles
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Birth control pill?
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Brand and dosage of BCP
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PMS Symptoms
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Menopause
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State of Menopause
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