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Patient Health Overview
  • All of your personal information
  • Family Health History
  • Female Reproductive
  • Male Reproductive
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Name
E-mail Address:
Street Address:
Street Address:
City
State/Province
Zip/Postal
Phone:
Ok to text?
Date of Birth:
Place of Birth:
Age:
Height: :
Current Weight:
Would you like your weight to be different?
How?
Occupation:
How many hours do you work per week?
Relationship Status:
Children?
Blood Type (if known)
Were you referred by another practitioner to our office?
Who referred you?
What are your top 5 health concerns in order of importance to you?
1.
2.
3.
4.
5.
Do you sleep well?
Do wake up during the night?
If so, what time(s)?
What time do you go to bed?
What time do you generally wake up in the morning?
How do you feel when you wake up?
Do you drink caffeinated drinks?
How much & how often?
Do you smoke
How much & how often do you smoke?
Why, how, and when did you quit smoking?
Have you ever been exposed to second-hand smoke?
How much, how often and for how long?
Do you drink alcohol?
How much & how often?
What role does exercise play in your life?
Have you been exposed to toxic substances at work or home?
How much water do you drink per day?

Maximum file size: 516MB

Do you have any known allergies to medications or herbs?
Are you currently under a practitioner’s care for a specific health issue?

Practitioner’s Info

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Please list any surgeries, accidents, injuries or childhood diseases you have had.

Birth to 2 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
2 years to 5 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
6 years to 10 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
11 years to 15 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
16 years to 20 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
21 years to 30 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
31 years to 40 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
41 years to 50 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
51 years to 60 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
61 years to 70 years old

Section

Please check all that applies
Illness
Accident
Injury
Surgery
70 years to Present

Section

Please check all that applies
Illness
Accident
Injury
Surgery
What percentage of your food is home cooked?
Choose one
Pick an option
Do you crave sugar?
Do you crave salt?
Do you feel tired, bloated, and/or gassy after meals?
Do you experience constipation or diarrhea often?
When and how often?
Do you experience constipation or diarrhea often?
When and how often?
Do you feel excessively hungry?
Do you have a poor appetite?