Name: Date:

Street:

City: State: Zip:

Home Phone: Work Phone:

E-mail: Emergency No.:

Age: Height: Weight: Sex: Male Female

Birthday: Occupation:

Physician: Referred by:

Main Problem: Onset (When):

Other Concurrent Therapies:

Past Medical History (Include Dates)
Significant Illnesses:
Cancer Diabetes High Blood Pressure

Heart Disease Hepatitis Seizures

Rheumatic Fever Thyroid Disease

Other (Please describe)

Surgeries:

Significant Trauma (Auto Accidents, Falls, etc.):

Birth History (Prolonged Labor, Forceps Delivery, etc.):

Allergies (Drugs, Chemicals, Foods, etc.):

Medicines taken within last two months (Include Vitamins, Over-the-counter Drugs, Herbs, etc.):

Occupational Stresses (Chemical, Physical, Psychological, etc.):

Exercise:

Comments:

Habits
Cigarettes Coffee Tea Cola/Soda Alcohol Drugs Sugar Salt

Other

Family Medical History
Diabetes Cancer High Blood Pressure Hearth Disease Stroke Seizures

Asthma Allergies Alcoholism

Other

Notes

General
Poor Appetite Heavy Appetite Poor Sleep Heavy Sleep Insomnia

Fatigue Tremors Vertigo Cold Hands Cold Feet Cold Back

Cold Abdomen Fevers Chills Night Sweats Sweats Easily

Localized Weakness Poor Coordination Change in Appetite

Sudden Energy Drop (note time of day)

Strong Thirst (Cold/Hot Drinks)

Bleed or Bruise Easily (note where)

Other

Skin and Hair
Rashes Ulcerations Hives Itching Eczema Pimples Dandruff

Loss of Hair Change in Hair/Skin Texture

Other Hair/Skin Problems

Head, Eyes, Ears, Nose, and Throat
Dizziness Concussions Eye Strain Eye Pain Cataracts Ear Aches

Ringing in Ears Poor Hearing Nose Bleeds Sinus Problems Mucus

Dry Throat Dry Mouth Teeth Problems Grinding Teeth Facial Pain

Gum Problems Spots in Eyes

Recurrent Sore Throat (note number of times per month)

Other

Cardiovascular
High Blood Pressure Low Blood Pressure Chest Pain Irregular Heart Beat

Dizziness Cold Hands Cold Feet Other

Respiratory
Cough Coughing Blood Asthma Bronchitis Pneumonia

Difficulty Breathing When Lying Down

Production of Phlegm (describe) (what color?)

Other Lung Problems

Gastrointestinal
Nausea Reflux Diarrhea Gas Belching Bad Breath Rectal Pain

Hemorrhoids Constipation Bloody Stools Pain or Cramps Bloated after Eating

Bowel Movement:
Frequency Color Odor Texture/Form

Laxatives Used (what type?) (number of times per week?)

Genito-Urinary
Pain on Urination Frequent Urination Blood in Urine Urgency to Urinate

Unable to hold Urine Kidney Stones

Wake up to Urinate (number of times per night?) (at what time(s)?)

Other G-U Problems

Pregnancy and Gynecology
Pregnancies (number) Births (number) Premature Births (number)

Miscarriages (number) Period Duration Flow (describe)

Age of first Menstruation Last PAP Last Menses

Irregular Periods Clots Menopause Vaginal Discharge Vaginal Sores

Breast Lumps Birth Control (type and duration)

Changes in Body/Psyche prior to Menstruation

Musculoskeletal
Neck Pain Osteoporosis Muscle Pain

Back Pain (describe type/where)

Joint Pain (describe type/where)

Other Joint or Bone Problems

Neuropsychological
Seizures Poor Memory Concussion Depression

Anxiety/Panic Attacks Treated for Emotional Problems

Other Neurological or Psychological Problems

Comments

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