Name * First Name Last Name Date MM DD YYYY Email * Date of Birth Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### What is your Occupation * Sex Male Female Other Are you married? Yes No Do you have children? Yes No How many children? Personal History: Current Complaint When did your symptoms start? Have you ever had this before? Yes No What was happening around the time your symptoms started? Previous Complaints, Surgeries, Past conditions Other Conditions Check conditions you frequently experience: Allergies Headaches Cold Flu Depression Acid Reflux Constipation Diarrhea Skin Problems Ear aches Mood changes Dizziness Eye problems Fever Any other Complaints, Symptoms or conditions I want most to have relief from Mental and Emotional What are your fears? What are your worries? Do you prefer to keep your feelings to yourself or do you like to express them? to myself express them Do you experience angry outbursts? Yes No After you have lost control what do you feel? relieved remorseful guilty angry at yourself still angry upset How does consolation from another person make you feel? Better Uncomfortable Nothing Do you have difficulty making decisions? Yes No Are you bothered by scary movies or unpleasant news on TV? Yes No Lifestyle and Habits When do you feel better? Doing things Sitting still Are you more of a morning person or a night person? Morning Person Night Person Do you plan things or prefer to go with the flow? Plan Things Go with the Flow What are your food cravings? Foods you have a strong aversion to? Foods or drinks which cause you discomfort? How do you prefer your drinks? Cold Ice cold Hot Room temperature Environmental Conditions Do you feel hot or cold more often? Hot Cold Do you usually feel better in warm or cool weather? Warm Cool Neither Does disorganization bother you? Yes No Do you keep your home neat and tidy? Yes No What are you usually sensitive to? Noise Light Touch Smell Suffering of others Taste Anything else you are sensitive to? Physical What are your energy levels throughout the day Very Low Low Moderate High Very High What weather conditions make you feel better? Winter Sunny Cloudy Thunderstorm Lightning Humidity Snowfall Summer Rains What weather conditions are you most troubled by? Winter Sunny Cloudy Thunderstorm Lightning Humidity Snowfall Summer Rains When are you thirsty? Day Night Never Always Social Behavior Do you enjoy meeting new people or prefer being with familiar faces? Do you prefer working independently or in a team setting? How do you celebrate achievements—quietly or with others? Are you an introvert or an extrovert? Bowel Habits Are you frequently constipated? Yes No Do you often have Diarrhea? Yes No Do you have abdominal bloating? Yes No Sleep Patterns Do you have difficulty falling asleep? Yes No Sometimes Do you have difficulty returning to sleep? Yes No Sometimes How do you feel while sleeping? Hot Cold Warm Restless In pain Sweaty Wonderful When you sleep at night you want the room to be? Warm Cool Quiet Dark Night lights on Describe your sleeping position: Do you cover yourself while sleeping? Describe the unusual dreams you had recently: How do you feel when you wake up in the morning? Women's Section At what age did your period begin? Was your period regular? Yes No Sometimes Is your period regular now? Yes No Sometimes How long does your period last? Have you ever had any major problems with your period? If so when? Please describe. Describe the quality of your period: color, clotting, etc. Current Medications Please list any current medications you are taking including supplements and/or herbs: Please list any past medications which you were on for a long time and/or you feel are still affecting you: Family Health History Father Mother Paternal Grandfather, Paternal Grandmother Maternal Grandfather, Maternal Grandmother Is there anything else you would like to share about your health? Please attach any health records you would like us to review. Congratulations you are done with this form. Appreciate your time. Go ahead and Submit it. Thank you! Health History Form
