Name
Date of Birth *
Address
City
Zip
Phone
Email *
Emergency Contact
Phone
Relation
For sliding scale purposes, annual family income
What is the main concern that has brought you here today?
If applicable, describe past treatment for this condition
Other health concerns? (list in order of importance)
If applicable, past treatments for this condition(s)
Please list any drugs, supplements, foods, medications, or environmental allergies or sensitivities
Please list any medications (prescribed or over the counter), vitamins or supplements you are taking, including dosage and how often you take them
Height
Weight
Past Minimum/Maximum Weight
When?
Do you have any infectious diseases?
Do you have any chronic conditions?
Reason for Hospitalizations / Surgeries
When?
Reason for Hospitalizations / Surgeries
When?
Reason for Hospitalizations / Surgeries
When?
Reason for Hospitalizations / Surgeries
When?
Reason for X-Rays / CT Scans / MRIs / Special Studies
When?
Reason for X-Rays / CT Scans / MRIs / Special Studies
When?
Reason for X-Rays / CT Scans / MRIs / Special Studies
When?
Color of the phlegm
When was the Stroke?
When was the Heart Attack?
Specify:
Which type?
Time of day at lowest energy:
Energy Level 1-10(10 highest):
How often do you experience panic attacks?
If you experience anxiety, is there a specific place in your physical body where you feel it?
Is there a particular emotion that has been dominant in your life recently?
Hours per night
Time to bed
Time at waking
Do you wake rested?
Where is the location of the Pain?
# of bowel movements per day
# of bowel movements per week
Where do you experience joint pain?
Which Type?
Location of paralysis:
What Type of Cancer?
When was your Hysterectomy?
Age at 1st period
Birth Control, if any
Length of cycle (one period to the next)
Pregnancies
Vaginal Births
C-Sections
of days of flow
Terminations
Miscarriages
VBACs
Date of last pap smear
Are you pregnant now?
How far along?
Breakfast
Lunch
Dinner
Snacks
Drinks
Glasses of water per day
Amount of caffeinated beverages per day
Food allergies/sensitivities
Foods you crave
Foods you restrict
Do you drink alcohol?
What kind, how much, how often?
Do you smoke?
How much, how often?
Recreational drug use?
What kind, how much, how often?
Do you exercise?
What kind, how much, how often?
Occupation
Employer
How many hours per week do you work?
Do you enjoy your job?
Why or why not?
Interests / Hobbies?
Anything else you’d like us to know?
