Health Questionnaire

General Information

Full name *

Email *

Phone (cell)

Phone (home)

Phone (work)

Age

Date of birth

Sex at birth

Current gender identity

Blood type

Address

City

State

ZIP

When, where and from whom did you last receive medical or health care?

Emergency contacts

Emergency contact 1

Relationship

Phone

Emergency contact 2

Relationship

Phone

Current Health Concerns & Allergies

Please rank current and ongoing health concerns in order of priority.

	Describe the problem	Severity	Prior treatment / approach	Success
1.
2.
3.
4.
5.
6.
7.
8.
9.

Allergies

	Name of medication / supplement / food	Reaction
1.
2.
3.
4.
5.

Readiness Assessment & Health Goals

What do you hope to achieve in your visit with us?

When was the last time you felt well?

Did something trigger your change in health?

What makes you feel better?

What makes you feel worse?

How does your condition affect you?

What do you think is happening and why?

What do you feel needs to happen for you to get better?

Sleep & Exercise

Sleep

How many hours of sleep do you get each night on average?

Problems falling asleep?

YesNo

Problems staying asleep?

YesNo

Do you feel rested upon awakening?

YesNo

Problems with insomnia?

YesNo

Do you snore?

YesNo

Do you use sleeping aids?

YesNo

Exercise

Your current activity

	Type	Times per week	Duration (minutes)
Cardio/Aerobic
Strength/Resistance
Flexibility/Stretching
Balance
Sports/Leisure (e.g., golf)
Other

Do you feel motivated to exercise?

YesA littleNo

Are there any problems that limit exercise?

YesNo

Do you feel unusually fatigued or sore after exercise?

YesNo

Nutrition

Caffeine, Smoking & Alcohol

Stress & Relationships

Personal History

Women's & Men's History

Please answer the part that applies to you and skip the other.

Women's history (skip if male)

Obstetric history (provide number for all that apply)

	Number
Pregnancies
Miscarriages
Abortions
Living Children
Vaginal Deliveries
Cesarean
Term Births
Premature Births

Largest baby birth weight

Smallest baby birth weight

Did you develop any problems in or after pregnancy? (Toxemia, Diabetes, Postpartum Depression, Breast-feeding Issues)

YesNo

Age of first cycle

Date of last cycle

Length of cycle

Time between cycles

Cramping?

YesNo

Pain?

YesNo

Have you had premenstrual problems?

YesNo

Men's history (skip if female)

Nocturia: # of times per night

Last PSA test (date)

PSA level

1-22-44-10>10

Other tests/procedures (list types and dates)

Family History

Check family members who have had any of the following:

Scroll sideways to see all family members.

	Mother	Father	Brother(s)	Sister(s)	Child 1	Child 2	Child 3	Child 4	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather	Other
Age if still alive
Age of death if deceased
Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Autoimmune Disease
Arthritis
Kidney Disease
Thyroid Problems
Seizures/Epilepsy
Psychiatric Disorders
Anxiety
Depression
Asthma
Allergies
Eczema
ADHD
Autism
Irritable Bowel Syndrome
Dementia
Substance Abuse
Genetic Disorders
Other

Notes (diabetes type, other conditions, etc.)

Personal Medical History

Check if you have had any of the following:

Musculoskeletal

FibromyalgiaOsteoarthritisChronic Pain

Skin

EczemaPsoriasisAcneSkin Cancer

Diagnostic studies

	Date	Additional information
Bone Density
CT Scan
Colonoscopy
Cardiac Stress Test
EKG
MRI
Upper Endoscopy
Chest X-Ray
Other

Injuries

	Date	Additional information
Concussion
Head Injury
Other

Surgeries

	Surgery	Date	Additional information
1.
2.
3.
4.

Hospitalizations

	Reason	Date	Additional information
1.
2.
3.

Symptom Review

Check if you have had any of the following, and write details in the box if you'd like to elaborate.

Medications & Supplements

Current medications

	Medication	Dosage	Start date	Reason for use
1.
2.
3.
4.
5.
6.
7.
8.

Current supplements

	Supplement	Dosage	Start date	Reason for use
1.
2.
3.
4.
5.
6.
7.
8.

Have medications or supplements ever caused unusual side effects or problems?

YesNo

Have you used any of these regularly or for a long time?

Tylenol (Acetaminophen)?

YesNo

NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin?

YesNo

Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)?

YesNo

How many times have you taken antibiotics?

Childhood

<5>5

Teen

<5>5

Adult

<5>5

Have you ever taken long-term antibiotics?

YesNo

How often have you taken oral steroids (cortisone, prednisone, etc.)?

Childhood

<5>5

Teen

<5>5

Adult

<5>5

General Information

Emergency contacts

Current Health Concerns & Allergies

Readiness Assessment & Health Goals

Sleep & Exercise

Sleep

Exercise

Nutrition

Please record what you eat in a typical day

Caffeine, Smoking & Alcohol

Caffeine

Smoking

Alcohol

Other substances

Stress & Relationships

Relationships

Personal History

Birth / childhood history

Dental history

Environmental / detoxification history

Women's & Men's History

Women's history (skip if male)

Men's history (skip if female)

Family History

Personal Medical History

Symptom Review

Medications & Supplements

Have you used any of these regularly or for a long time?

How many times have you taken antibiotics?

How often have you taken oral steroids (cortisone, prednisone, etc.)?

Readiness & Final Thoughts