Medical History Questionairre

Sections
Contact and Birth Information
Your Chief Complaints
Your General Health
Your Health History
Family Health History
Musculoskeletal System
Cardiovascular System
Endocrine System
Sleep and Dreams
Blood, Lymph, Immune Systems
Respiratory System
Nervous System
Skin and Hair
Digestive System
Urogenital System
Female Problems
General Symptoms
Mental and Emotional
    • First Name
    • Last Name
    • Date
    • Age
    • Sex
    • Birth Date
    • Birth Time
    • Place of Birth
    • Phone(Home)
    • Phone(Work)
    • Phone(Cell)
    • Email Address
    • Marital Status
    • What profession or type of work do you do? Fulltime? Part-time? Retired?
    • Referred By:
    • In your opinion, what are your most important health problems? List as many as you can in order of importance:
    • Comments about your most important health problems:
    • On a scale of 1-10, how do you rate your health now?
    • The general state of my health has been:
    •  Excellent Good Fair Poor
    • How is your general vitality, stamina, and energy?
    • Are you a warm or chilly person?
    • Are you a thirsty person?
    • Do you prefer warm or cold drinks?
    • When did your complaint or ailment begin?
    • What do you think causes or has caused your aliment or complaint?
    • Have you had an experience (traumatic or otherwise) that did or still does affect you deeply? Explain.
    • What do you think causes or has caused your aliment or complaint?
    • Disease
    • When
    • Disease
    • When
    • Rubella (3 day measles)
    • Mumps
    • Measles (two week)
    • Chickenpox
    • Whooping Cough
    • Asthma
    • Scarlet Fever
    • Polio
    • Rheumatic Fever
    • Others
    • If you have had any of the following tests or immunizations, place an (X) on the appropriate line. If you can, give the year you last had them:
    • Year
    • Test
    • Year
    • Immunizations
    • Chest X-ray
    • Smallpox
    • Kidney X-ray
    • Tetanus
    • G.I. Series
    • Polio
    • Colon X-ray
    • Typhoid
    • Gallbladder X-ray
    • Flu
    • Electrocardiogram
    • Mumps
    • T.B. Test
    • Measles
    • Other X-rays
    • Rubella
    • Diphtheria
    • Other
    • Hospitalizations: (list as best you can)
    • Type of illness/operation
    • Date
    • Location
    •  Now Past Never
    • Allergies
    •  Now Past Never
    • Emphysema
    •  Now Past Never
    • Anemia
    •  Now Past Never
    • Heart Condition
    •  Now Past Never
    • Arthritis
    •  Now Past Never
    • Kidney Disease
    •  Now Past Never
    • Gout
    •  Now Past Never
    • Liver Disease
    •  Now Past Never
    • Hepatitis
    •  Now Past Never
    • Obesity
    •  Now Past Never
    • Anorexia
    •  Now Past Never
    • Bulimia
    •  Now Past Never
    • Asthma
    •  Now Past Never
    • High Blood Pressure
    •  Now Past Never
    • Bleeding
    •  Now Past Never
    • Injury (serious)
    •  Now Past Never
    • Bruising
    •  Now Past Never
    • Pneumonia
    •  Now Past Never
    • Cancer
    •  Now Past Never
    • Rheumatism
    •  Now Past Never
    • Tumors
    •  Now Past Never
    • Thyroid Trouble
    •  Now Past Never
    • Colitis
    •  Now Past Never
    • Tuberculosis
    •  Now Past Never
    • Convulsions
    •  Now Past Never
    • Epilepsy
    •  Now Past Never
    • Mental Disease
    •  Now Past Never
    • Ulcers
    •  Now Past Never
    • Depression
    •  Now Past Never
    • Migraine Headache
    •  Now Past Never
    • Diabetes
    •  Now Past Never
    • Drinking
    •  Now Past Never
    • Drugs
    •  Now Past Never
    • Herpes
    •  Now Past Never
    • Eczema
    •  Now Past Never
    • AIDS
    •  Now Past Never
    • Sexually Transmitted Diseases (STD’s ) Venereal- Gonorrhea, Syphilis, other)
    • Which STD’s and when:
    • Which of these do you use:
    • Yes
    • Amount
    • Yes
    • Amount
    •  Coffee
    •  Birth Control
    •  Cigarettes
    •  Sedatives
    •  Alcohol
    •  Tranquilizers
    •  Aspirin
    •  Thyroid
    •  Other Drugs
    •  Laxatives
    •  Electric Blanket
    •  Cortisone
    •  Herbs and Teas
    •  Hormones
    •  Recreational Drugs
    •  Vitamins
    •  Other Therapies
    • Are you allergic to any drugs?
    • Are you allergic to any foods or other substances?
    • What happens when you have an allergic attack or reaction?
  • If deceased, list the cause of death and age at death.
    • Relation
    • Living
    • Deceased
    • Cause
    • Age
    • Your Mother
    • Your Father
    • Your Brother(s)
    • .
    • Your Sister(s)
    • .
    • Mother's Side
    • Your Grandfather
    • Your Grandmother
    • Father's Side
    • Your Grandfather
    • Your Grandmother
  • Has any blood relative had any of the following?
    •  Yes No Unknown
    • Allergies
    •  Yes No Unknown
    • Hay Fever
    •  Yes No Unknown
    • Anemia
    •  Yes No Unknown
    • Heart Attack
    •  Yes No Unknown
    • Arthritis
    •  Yes No Unknown
    • High Blood Pressure
    •  Yes No Unknown
    • Asthma
    •  Yes No Unknown
    • Seizure or Epilepsy
    •  Yes No Unknown
    • Bleeding
    •  Yes No Unknown
    • Sickle Cell Anemia
    •  Yes No Unknown
    • Cancer
    •  Yes No Unknown
    • Stroke
    •  Yes No Unknown
    • Diabetes
    •  Yes No Unknown
    • Thyroid Trouble
    •  Yes No Unknown
    • Depression
    •  Yes No Unknown
    • Tuberculosis
    •  Yes No Unknown
    • Eczema
    •  Yes No Unknown
    • Venereal Disease
    •  Yes No Unknown
    • Glaucoma
    •  Yes No Unknown
    • Gout
  • Neck
    •  Now Past
    • stiffness
    •  Now Past
    • whiplash
    •  Now Past
    • pain, swelling
    •  Now Past
    • injuries
    •  Now Past
    • radiating pain
  • Middle Back
    •  Now Past
    • stiff, painful
    •  Now Past
    • injuries
    •  Now Past
    • herniated disc(s)
    •  Now Past
    • radiating pain
    •  Now Past
    • arthritis
  • Low Back, Sacrum
    •  Now Past
    • stiff, painful lower back
    •  Now Past
    • arthritis
    •  Now Past
    • radiating pain
    •  Now Past
    • injuries
    •  Now Past
    • herniated disc(s)
  • Limbs
    •  Now Past
    • joint pain, swelling, stiffness, tingling, numbness
  • Where?
    •  Now Past
    • muscles cramps
    •  Now Past
    • burning of soles of feet
    •  Now Past
    • unusual redness of the palms or hands
    •  Now Past
    • arthritis
  • Where?
  • What kind?
    •  Now Past
    • injuries
  • Where?
    •  Now Past
    • chest pain when walking
    •  Now Past
    • leg vain problems
    •  Now Past
    • ankle swelling
    •  Now Past
    • leg pain when walking
    •  Now Past
    • high blood pressure
    •  Now Past
    • shortness of breath
    •  Now Past
    • heart palpitations
    •  Now Past
    • excessive hair
    •  Now Past
    • prefer cold weather
    •  Now Past
    • cold hands or feet
    •  Now Past
    • unexplained weight gain/loss
    •  Now Past
    • prefer hot weather
    •  Now Past
    • increased thirst
    •  Now Past
    • weakness
    •  Now Past
    • increased hunger
    •  Now Past
    • can’t stand cold
    •  Now Past
    • can’t stand heat
    •  Now Past
    • chronic fatigue
    •  Now Past
    • excess sweating
    • Do you have any history of sleep problems or irregular sleep patterns?
    • Sleepy during the day?
    •  Yes No
  • When?
    • Do you usually dream?
    •  Yes No
    • Do you remember your dreams?
  • Any recurring themes?
    •  Now Past
    • insomnia
    •  Now Past
    • nightmares/bad dreams
    •  Now Past
    • wakes unrefreshed
    •  Now Past
    • too hot or cold during sleep
    •  Now Past
    • sleep deprivation
    •  Now Past
    • night sweats
    •  Now Past
    • swollen lymph nodes
    •  Now Past
    • chronic fatigue
    •  Now Past
    • wounds heal slowly
    •  Now Past
    • fevers or chills
    •  Now Past
    • difficulty stopping bleeding
    •  Now Past
    • blood transfusions
    •  Now Past
    • anemia, tires easily
    •  Now Past
    • re-occurring infections
    •  Now Past
    • bleeding from unusual places
    •  Now Past
    • bruises easily
    •  Now Past
    • swollen glands
    •  Now Past
    • unexplained illness
    • respiratory-system

    •  Now Past
    • unexplained coughs
    •  Now Past
    • chest pain when breathing
    •  Now Past
    • mucus in lungs
    •  Now Past
    • shortness of breath
    •  Now Past
    • wheezing, asthma
    •  Now Past
    • chronic cough
    •  Now Past
    • difficulty breathing
    •  Now Past
    • lung infections
    •  Now Past
    • difficulty breathing at night
    •  Now Past
    • tobacco smoking
    •  Now Past
    • loss of balance
    •  Now Past
    • paralysis
    •  Now Past
    • convulsions, seizures
    •  Now Past
    • lack of strength
    •  Now Past
    • tremors
    •  Now Past
    • numbness
    •  Now Past
    • involuntary movement
    •  Now Past
    • nerve pain
    •  Now Past
    • rough, dry, scaly, bumpy, itchy
    •  Now Past
    • acne
    •  Now Past
    • moles
    •  Now Past
    • boils, abscess
    •  Now Past
    • cysts
    •  Now Past
    • oily skin
    •  Now Past
    • dry, cracked skin
    •  Now Past
    • hair loss
    •  Now Past
    • light or dark patches
    •  Now Past
    • eczema
    •  Now Past
    • increased hair growth
    •  Now Past
    • dermatitis
    •  Now Past
    • age spots
    •  Now Past
    • sensitive skin
    •  Now Past
    • color changes in nails
    •  Now Past
    • wrinkles, premature
    •  Now Past
    • hives, rashes
    •  Now Past
    • blackheads, clogged pores
    •  Now Past
    • infections
    •  Now Past
    • scars, keloids
    •  Now Past
    • ridges, pits or spots on nails
    •  Now Past
    • warts
    •  Now Past
    • acid reflux
    •  Now Past
    • vomiting, nausea
    •  Now Past
    • blood in stool
    •  Now Past
    • diarrhea
    •  Now Past
    • constipation
    •  Now Past
    • fissures
    •  Now Past
    • change in bowel movements
    •  Now Past
    • anal itching
    •  Now Past
    • black or white stools
    •  Now Past
    • vomiting blood
    •  Now Past
    • heartburn
    •  Now Past
    • gas and bloating
    •  Now Past
    • excess belching
    •  Now Past
    • jaundice
    •  Now Past
    • stomach pain and aches
    •  Now Past
    • painful swallowing
    •  Now Past
    • distress from fats or greasy foods
    •  Now Past
    • worms, parasites
    •  Now Past
    • foul stools, undigested food
    •  Now Past
    • colitis
    •  Now Past
    • bad breath, bad taste in mouth
    •  Now Past
    • surgeries, injuries
    •  Now Past
    • indigestion after meals
    •  Now Past
    • poor assimilation
    •  Now Past
    • heavy, full feeling after eating
    •  Now Past
    • weight gain or loss
    •  Now Past
    • excessive lower bowel gas
    •  Now Past
    • food allergies
    •  Now Past
    • stomach pain 5-6 hours after eating
    •  Now Past
    • special diets
    •  Now Past
    • foul body odor
    •  Now Past
    • overweight
    •  Now Past
    • sudden weight loss
    •  Now Past
    • loss of appetite
    •  Now Past
    • sudden weight gain
    •  Now Past
    • infection
    •  Now Past
    • nervous, shaky, headaches; relieved by eating
    •  Now Past
    • irritability related to missing meals
    •  Now Past
    • sudden, strong cravings
    •  Now Past
    • waking up hungry at night
    •  Now Past
    • injury
    • How often do you have bowel movements?
    • Stool (formed or loose)?
    • What does your diet consist of?
    • How frequently do you eat?
    • What food(s), condiments(s), or any other substances (i.e. tobacco, alcohol, coffee) do you crave?
    •  Now Past
    • frequent urination
    •  Now Past
    • painful urination
    •  Now Past
    • night urination
    •  Now Past
    • trouble starting urine
    •  Now Past
    • trouble holding
    •  Now Past
    • blood in urine
    •  Now Past
    • prostate problems
    •  Now Past
    • difficulty with ejaculation
    •  Now Past
    • discharge from penis
    •  Now Past
    • lumps or swelling in testicles
    •  Now Past
    • erectile dysfunction
    •  Now Past
    • infection
    •  Now Past
    • painful erection
    •  Now Past
    • infertility
    •  Now Past
    • injury
    • What contraception do you use?
    •  Now Past
    • discharge from vagina
    •  Now Past
    • spotting between periods
    •  Now Past
    • difficulty feeling aroused
    •  Now Past
    • infection
    •  Now Past
    • no lubrication when aroused
    •  Now Past
    • infertility
    •  Now Past
    • never or seldom orgasm
    •  Now Past
    • menstrual flow is absent
    •  Now Past
    • sex is painful
    •  Now Past
    • menstrual flow is excessive
    •  Now Past
    • pain before period
    •  Now Past
    • pain during period
    •  Now Past
    • pain after period
    •  Now Past
    • lumps in breast
    • Do you have premenstrual symptoms like cramping, water retention, breast tenderness, headaches, depression, or irritability? Please describe.
  • Menses
    • Period every days.
    • Regular?
    •  Yes No
    • Period usually lasts days.
    • Average flow is
    •  Light Medium Heavy
    • Date of last period:
    • Number of Pregnancies:
    • Number of Births:
    • Nursed Children:
    • Trouble with lactation?
    • Number of Miscarriages:
    • Date(s):
    • Number of Abortions:
    • Date(s):
    • Any complaints during pregnancy?
    •  Yes No
    • If yes, please list:
    • How old were you when you started having menstrual periods?
    • Do you have any nipple discharge?
    •  Yes No
    • What form of contraception do you use?
    • Hair
    •  Now Past
    • dandruff
    •  Now Past
    • damage from treatments
    •  Now Past
    • hair loss
    •  Now Past
    • dry hair
    •  Now Past
    • baldness
    •  Now Past
    • oily hair
    • Head
    •  Now Past
    • dizziness
    •  Now Past
    • migraines
    •  Now Past
    • severe headaches
    •  Now Past
    • fainting spells
    •  Now Past
    • seizures or fits
    •  Now Past
    • nerve pains
    •  Now Past
    • head injuries
    •  Now Past
    • facial paralysis
    • Eyes
    •  Now Past
    • infections
    •  Now Past
    • bloodshot eyes
    •  Now Past
    • light hurts eyes
    •  Now Past
    • blurry vision
    •  Now Past
    • double vision
    •  Now Past
    • weak vision
    •  Now Past
    • glaucoma
    •  Now Past
    • eyestrain
    •  Now Past
    • poor eyesight (near or far-sighted)
    •  Now Past
    • injuries
    • Ears
    •  Now Past
    • discharge from ears
    •  Now Past
    • ear infections
    •  Now Past
    • pain in ears
    •  Now Past
    • injuries
    •  Now Past
    • hearing troubles
    •  Now Past
    • ringing in ears
    •  Now Past
    • excessive earwax
    •  Now Past
    • deafness
    • Nose
    •  Now Past
    • nosebleeds
    •  Now Past
    • sensitive smell
    •  Now Past
    • mucus, nasal congestion
    •  Now Past
    • loss of smell
    •  Now Past
    • sinus problems
    •  Now Past
    • post nasal drip
    •  Now Past
    • difficulty breathing through nose
    •  Now Past
    • injuries
    • Mouth
    •  Now Past
    • sore mouth or tongue
    •  Now Past
    • discolored/brittle teeth
    •  Now Past
    • speech difficulties
    •  Now Past
    • mouth sores/ulcers
    •  Now Past
    • loss of teeth
    •  Now Past
    • tooth aches
    •  Now Past
    • gum bleeding
    •  Now Past
    • receding gums
    •  Now Past
    • gum infections
    •  Now Past
    • cavities
    • Throat
    •  Now Past
    • hoarseness
    •  Now Past
    • soreness
    •  Now Past
    • difficulty swallowing
    •  Now Past
    • chocking
    •  Now Past
    • loss of voice
    •  Now Past
    • sores/ulcers
    •  Now Past
    • laryngitis
    •  Now Past
    • swelling
    •  Now Past
    • mucus
    •  Now Past
    • sensitivity
    • Mental and Emotional
    •  Now Past
    • anxiety
    •  Now Past
    • feel better from exercise
    •  Now Past
    • fears or phobias
    •  Now Past
    • lack of motivation
    •  Now Past
    • nervousness, restlessness
    •  Now Past
    • mental fatigue
    •  Now Past
    • poor self confidence
    •  Now Past
    • insomnia
    •  Now Past
    • memory trouble
    •  Now Past
    • trouble concentrating
    •  Now Past
    • anger or irritability
    •  Now Past
    • crying spells
    •  Now Past
    • feeling of worthlessness
    •  Now Past
    • depression
    •  Now Past
    • trouble getting along w/others
    •  Now Past
    • suicidal thoughts
    •  Now Past
    • mood swings
    •  Now Past
    • easily upset or disappointed
    •  Now Past
    • obsessive behaviors
    •  Now Past
    • loss of emotional control
    •  Now Past
    • brain fog
    •  Now Past
    • panic attacks
    •  Now Past
    • fear of public speaking
    •  Now Past
    • history of being abused
    •  Now Past
    • put yourself last
    •  Now Past
    • emotional shocks, trauma
    •  Now Past
    • see things others don’t
    •  Now Past
    • suppressed anger or grief
    •  Now Past
    • hear voices
    •  Now Past
    • alcohol or drug addictions
    •  Now Past
    • think others want to hurt you
    •  Now Past
    • deep grief
    •  Now Past
    • trouble dealing with stress
    •  Now Past
    • excess stress
    •  Now Past
    • late for appointments
    •  Now Past
    • timid
    • How would you like to improve your health? (i.e. skin, hair, weight, teeth, etc.)
    • Are you presently on any of these treatments?
    •  Yes
    • Oil Pulling
    •  Yes
    • Detox Baths
    •  Yes
    • Herbal Teas/Tinctures
    •  Yes
    • Foot Baths
    •  Yes
    • Chiropractic Treatments
    •  Yes
    • Homeopathic Remedies
    •  Yes
    • Oil Massages
    •  Yes
    • Homeopathic Cell Salts
    •  Yes
    • Foot Oil Massages
    •  Yes
    • Natural Cosmetics
    •  Yes
    • Breast Massages
    •  Yes
    • Colonics/Enemas
    •  Yes
    • Testes Tapping
    •  Yes
    • Lucid Dream Therapy
    •  Yes
    • Qigong/Tai-Chi/Yoga
    •  Yes
    • Inhalation Therapy
    •  Yes
    • Qigong Self Massage
    •  Yes
    • Tonics
    •  Yes
    • Standing Meditations
    •  Yes
    • Other Therapies
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