HEALTH HISTORY
Patient Name _______________________________________Date of Birth___________ Age_______
Main health concern and recent history: ___________________________________________________
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PAST MEDICAL HISTORY: please mark if you now have, or have ever had, the following:
Migraine Headaches ________ STD’s____________________ Glaucoma________________
Heart Attack ______________ Mononucleosis_____________ Sleep Apnea _____________
Hernia (type?) _____________ GermanMeasles/Polio/Tuberculosis Hayfever/Allergies ________
Bleeding Disorder __________ HIV/AIDS__________________ Heart Valve Problems______
Rheumatic Fever ___________ Ulcer______________________ Anemia _________________
High Cholesterol ___________ Irritable Bowel Syndrome______ Kidney Stones ____________
Arthritis (type?) ___________ Diabetes (type?) _____________ Hemorrhoids _____________
Blood clots/phlebitis ________ Cancer(type?) _______________ Hepatitis (type?) ___________
Bladder infections__________ Low/ High Thyroid ___________ Asthma _________________
High Blood Pressure________ Gout_______________________ Emphysema ______________
Low Blood Pressure________ Gallstones___________________ Bronchitis _______________
Pneumonia________________ Back Pain___________________ Stroke ___________________
Blood Transfusions_________ Osteoporosis_________________ Seizures _________________
Any other illnesses or problems? ________________________________________________________
PREVIOUS SURGERY/INJURY/HOSPITALIZATIONS:
________________________________________________
________________________________________________
​WHEN? ​WHERE?
​__________ ​ ________________
​__________ ​ ________________
​ _________ ​ ________________
_
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IMMUNIZATIONS: Childhood ____________Last tetanus _______Hep B ________Pneumonia_____
WOMEN: Last pap smear?__________Any abnormal paps?________Last mammogram?___________
# of pregnancies?_____Births?______Miscarriages?_______ Birth control(what kind)?____________
GENERAL: Last Colonoscopy?_____________ MEN: Last prostate exam?______________________
MEDICATIONS: (include non-prescription)_______________________________________________
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SUPPLEMENTS/VITAMINS:__________________________________________________________
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SOCIAL HISTORY: Single_____ Married___​__ Separated______ Divorced______ Widowed______
Sexually active? __________ With: Man ______ Woman ________ Both________
Steady partner? ______ How long?________ Any history of abuse? (ever) ______________________
OCCUPATION: _______________________CHILDREN?___________AGES:__________________
COFFEE: Cups per day(caf.)_______, (decaf.)________ Caffeinated sodas/day_______ Tea _______
SMOKING: Never ____ Ex-smoker ____ quit when _______ Current smoker ____packs/day________
DRUG USE: Past __________________Current __________________
ALCOHOL: Amount _________ Frequency __________ Drinking Problem? Now______ Past______
EXERCISE: type ________________ duration ______________ frequency _____________
DIET: Vegetarian? ____ Vegan? ____ Eat Meat ____ how often? ____ Eat fish ____ how often?______
Fruits/vegetables-how many servings*/day? _________Sugars/sweets per day?_________________
Sodas per day: diet ____ regular _____ Eat “junk food”? ____ type?__________ how often?_________
Amount of water daily? ___________ Eat breakfast? __________ Hours of sleep/night:_____________
*1 serving = ½ cup raw veggies, 1 cup raw greens, ½ c most fruit, sm apple, ½ banana, 1 c berries, etc
PLEASE COMPLETE OTHER SIDE
ENVIRONMENT: any toxic exposures, past or recent? ______________________________________
FOREIGN TRAVEL?
​ Where, when, for how long?
__________________________________________
ALLERGIES: DRUGS: (list)____________________________________________________________
________________________________FOODS:_________________OTHER:____________________
FAMILY HISTORY: (MGM= maternal grandmother, etc.)
Age: Diseases/Conditions:
​If deceased, cause of death:
Father
Mother
Siblings
MGM
MGF
PGM
PGF
Other
REVIEW OF SYSTEMS: Please mark if you have any of these symptoms, “N” for now, “P” for past
GENERAL:
GASTROINTESTINAL:
GENITOURINARY:
Recent weight gain _________ Loss of appetite ____________ Frequent urination __________
Recent weight loss __________ Change/bowel movements ___ Burning on urination ________
Fever ____________________ Nausea or vomiting_________ Blood in urine _____________
Fatigue __________________ Diarrhea__________________ Decreased urine stream ______
Headaches ________________ Constipation ______________ Incontinence ______________
EYES/EARS/THROAT:
Blood in stool _____________ Urinating often at night ______
Wear glasses/contacts _______ Abdominal pain ____________ Sexual difficulties __________
Distorted vision ____________ Bloating/excess gas _________ Male: testicle pain ________
Eye irritation ______________ MUSCULOSKELETAL:
penis discharge __________
Ear pain __________________ Joint pain/swelling __________ Female: Painful periods ___
Ear ringing ________________ Muscle weakness ___________ irregular periods _________
Hearing loss _______________ Muscle pain/cramps _________ heavy periods ___________
Sore throat ________________ Back/neck pain ____________
vaginal discharge ________
Swollen neck glands ________ Difficulty walking __________ pelvic pain _____________
Hoarse/voice change ________ SKIN/BREASTS:
hot flashes _____________
Mouth sores _______________ Itching ___________________ postmenopausal _________
Bleeding gums _____________ Rash _____________________ PSYCHIATRIC/ENDOCRINE:
Sinus congestion ___________ Tick bite __________________ Anxiety __________________
Nose bleeds _______________ Dry skin __________________ Depression ________________
CARDIOVASCULAR:
Change in hair _____________ Insomnia__________________
Chest pain ________________ Varicose veins _____________ Memory loss ______________
Palpitations _______________ Breast lump _______________ Feeling cold often __________
Hard to breathe w/exercise ___ Breast pain ________________ Feeling hot often ___________
Hard to breathe lying flat ____ Breast discharge ___________ Cold hands/feet ____________
Swelling of ankles __________ NEUROLOGIC:
Easy bruising ______________
RESPIRATORY:
Dizzy/lightheaded __________ Slow to heal from cuts _______
Coughing _________________ Numbness/tingling _________ Swollen glands _____________
Shortness of breath _________ Tremors __________________ Excessive thirst ____________
Wheezing _________________ Paralysis _________________ Any other symptoms?
Coughing up blood ________ Head injury _______________ _________________________
Coughing up phlegm________ Fainting spells _____________ _________________________