Patient Data

Mailing address

Current Complaints

Insurance Information

* If an auto accident, please provide:

Medical History

Have you ever:

Family History

Other Medical Conditions

Habits

EMOTIONAL HEALTH

HOBBIES

EXERCISE

VOCATION

REFERRAL

PREVIOUS MEDICAL TREATMENTS

(Name, Type of Therapy, For What, When Treated, Helpful?)
(Diagnosis, Problem Started, How Diagnosed, Treatment, Result)

OB/GYN

HOSPITALIZATIONS AND SURGICAL PROCEDURES

(Surgery or Procedure, Date, Reason, Result/Scars)
(Grandmother, Grandfather, Mother, Father, Brothers/Sisters, Other)

TOBACCO/ALCOHOL

PREVIOUS MEDICATIONS

(Medicine/Dose, Why, How Long, Effects, Prescribed By)

PREVIOUS SUPPLEMENTS

(Supplements/Dose, Why, How Long, Effects, Prescribed By)

SLEEP PATTERNS

DIET

(Breakfast, Lunch, Dinner, Snacks)

How much of the following do you consume each day or week?

Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly
Daily/ Weekly

CURRENT MEDICAL TREATMENT

Name / Phone / Specialty / Condition(s) treated / Helpful?

CURRENT MEDICATIONS

(Medication/Dose, Why, How Long, Effects, Prescribed By)

CURRENT SUPPLEMENTS

(Supplement/Dose, Why, How Long, Effects, Prescribed By)

ALLERGIES

(Allergy, Type of Reaction)

SYMPTOM

GENERAL

EYES

EARS

EATING

MUSCULAR

MOOD/NERVES

DIGESTION

SKIN

NAILS

RESPIRATORY

URINARY

MALE

FEMALE REPRODUCTIVE

Enter date ranges

PREGNANCIES: (INDICATE NUMBER)

ENVIRONMENTAL QUESTIONS

Have you ever or do you use any of the following at/near home or work?

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