Health And Well-Being History Form

Please answer the following questions honestly and to the best of your ability.

Name

E-mail

Address

Phone

Date

Date of Birth

Refered by

Describe the problem (s) for which you seek therapy. Include dates when the each problem or injury occurred:

Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates:

List the medications (including over the counter) you are presently taking:

Have you ever had this problem before? If so, when?

What are your goals for treatment?

Please list any other kind of health care professional you are seeing for this problem:

List any medical tests and results you have had within the past year:

Please mark the circle that best describes the frequency you experience the below conditions.
*Leave BLANK if not ever a problem.

1. Rarely (once a month or less).
2. Occasionally (less than once a week).
3. Frequently (more than once a week).
4. Constantly.

DIGESTION

STOMACH/SPLEEN

Loose stools or Diarrhea

1 2 3 4

Acid reflux

1 2 3 4

Stomach or Intestinal pain

1 2 3 4

Constipation

1 2 3 4

Hiatal Hernia

1 2 3 4

Heartburn

1 2 3 4

Poor digestion

1 2 3 4

Nausea / vomiting

YES NO

Excessive appetite

1 2 3 4

Parasites

YES NO

Gas or belching

1 2 3 4

Poor appetite

1 2 3 4

COLON

Irritable bowels

1 2 3 4

Blood in stools

1 2 3 4

Black or dark stools

1 2 3 4

Hemorrhoids

1 2 3 4

LIVER/GALL BLADDER

Light colored stools

1 2 3 4

Difficulty digesting oily foods

1 2 3 4

High cholesterol

YES NO

Gall stones

YES NO

RESPIRATORY

LUNG

Wet cough

1 2 3 4

Poor sense of smell

1 2 3 4

Pneumonia

YES NO

Dry cough

1 2 3 4

Sinus problems

1 2 3 4

Asthma

YES NO

Chest tightness

1 2 3 4

Allergies

1 2 3 4

Emphysema

YES NO

Shortness of breath

1 2 3 4

Hay fever

1 2 3 4

Bronchitis

YES NO

Congestion

1 2 3 4

Catches colds easily

1 2 3 4

Wheezing

1 2 3 4

Do you smoke?

YES NO

If smoke, number per day:

Nasal problems

1 2 3 4

Other

1 2 3 4

Other

1 2 3 4

CARDIOVASCULAR

HEART

Hypertension

YES NO

Restless

1 2 3 4

Poor blood clotting

YES NO

Hypotension

YES NO

Heart palpitation

1 2 3 4

Heart disease

YES NO

Chest pain

1 2 3 4

Slow heart rate

1 2 3 4

Phlebitis

YES NO

Dizziness

1 2 3 4

Poor circulation

YES NO

Blood clots

YES NO

Easily bruised

1 2 3 4

Edema

1 2 3 4

Anemia

YES NO

Heart attack

YES NO

Heart attack, quantity?

Cold hands/feet

1 2 3 4

Stroke

YES NO

Stroke, quantity?

Other

1 2 3 4

URINARY

KIDNEY/BLADDER

Painful urination

1 2 3 4

Ringing in ears

1 2 3 4

Kidney stones

YES NO

Incontinence

1 2 3 4

Ear aches

1 2 3 4

Kidney infections

YES NO

Difficulty with urination

1 2 3 4

Hearing impairment

YES NO

Low back pain

YES NO

Knee problems

YES NO

Other

1 2 3 4

NERVOUS SYSTEM

Shaky

1 2 3 4

Epilepsy

YES NO

Dyslexia

YES NO

Head injury

YES NO

Numbness?

YES NO

Where?

Learning disorder

YES NO

Tingling?

YES NO

Where?

Multiple Sclerosis

YES NO

Other

1 2 3 4

Muscular Dystrophy

YES NO

Developmental or growth YES NO problems?

YES NO

Type?

Nervous disorder?

YES NO

Type?

MUSCLES/JOINTS

TMJ pain

1 2 3 4

Joint swelling

1 2 3 4

Facial pain

1 2 3 4

Osteoarthritis

YES NO

Loss of balance

1 2 3 4

Rheumatoid Arthritis

YES NO

Poor Coordination

1 2 3 4

Poor posture

YES NO

Leg weakness

1 2 3 4

Arm weakness

1 2 3 4

Trunk weakness

1 2 3 4

Difficulty walking

1 2 3 4

Broken bones or fractures?

YES NO

Where?

Artificial joints

YES NO

Metal fixation?

YES NO

Where?

CHECK PAINFUL AREAS

Shoulder

R L

Neck

R L

Arm

R L

Upper back

R L

Elbow

R L

Mid back

R L

Hands

R L

Low back

R L

Hip

R L

Legs

R L

Knees

R L

Feet

R L

Limitation of movement; where?

OTHER

Insomnia

1 2 3 4

Fatigue

1 2 3 4

Fibromyalgia

YES NO

Depression

1 2 3 4

Difficulty with speech

1 2 3 4

Poor sense of smell

YES NO

No thirst

1 2 3 4

Shaky

1 2 3 4

Poor sense of taste

YES NO

Dry mouth

1 2 3 4

Poor memory

1 2 3 4

Herpes

YES NO

Pain at night

1 2 3 4

Difficulty paying attention

1 2 3 4

Shingles

YES NO

Headaches

1 2 3 4

Anxiety

1 2 3 4

Migraines

1 2 3 4

Easily angered

1 2 3 4

Dental problems

YES NO

Eye pain

1 2 3 4

Tendency to be obsessive in work or relationships.

1 2 3 4

Candida

YES NO

Dry Eyes

1 2 3 4

Watery Eyes

1 2 3 4

Difficulty swallowing

YES NO

Difficulty making plans or decisions

1 2 3 4

Dizziness

1 2 3 4

Diabetes

YES NO

Intolerance to temperature or weather

1 2 3 4

Fever

1 2 3 4

Soft or brittle nails

YES NO

Chills

1 2 3 4

Nose bleeds

1 2 3 4

Weight gain

YES NO

Swollen glands

1 2 3 4

Weight loss

YES NO

Tuberculosis

YES NO

Thyroid problems

YES NO

Sleep too much?

YES NO

How long?

Cancer?

YES NO

Where?

Allergies?

YES NO

Allergies (list)

Hepatitis?

YES NO

Type?

Other Eye problems?

YES NO

Eye problems:

Infectious disease?

YES NO

Infectious disease? (explain)

Chemical dependency?

YES NO

Chemical dependency? (drugs or alcohol)

Skin Condition?

YES NO

Skin Condition (explain)

Other:

YES NO

OTHER

Prostate problems

1 2 3 4

Pain associated with genitals

1 2 3 4

Prostate cancer

YES NO

Impotence

1 2 3 4

Problems urinating

1 2 3 4

Infertility

YES NO

Other:

YES NO

OTHER

Breast pain or tenderness

1 2 3 4

Endometriosis

YES NO

Breast lumps

YES NO

PMS

YES NO

Nipple discharge

YES NO

Painful menses?

YES NO

Infertility

YES NO

Menopause

YES NO

Heavy or excessive flow?

YES NO

Painful intercourse

YES NO

Ovarian cysts

YES NO

Are your cycles regular; length of cycle?

YES NO

Menopausal symptoms?

YES NO

Other:

YES NO

Please mark the circle that best describes the level of stress for the below listings.

My family stress is:

None Minimal Moderate Severe

My relationship stress is:

None Minimal Moderate Severe

My work stress is:

None Minimal Moderate Severe

My ﬁnancial stress is:

None Minimal Moderate Severe

My health stress is:

None Minimal Moderate Severe

Other stress is

None Minimal Moderate Severe

Other stress is

None Minimal Moderate Severe

Other stress is

None Minimal Moderate Severe

How much time do you have for yourself to relax and what do you do to relax, ie. hobbies, meditation, etc ?

Do you exercise? And if so, what kind and how often?

How many hours a night do you sleep?

Is your sleep restful?

If not, describe:

Please list areas of pain and mark the circle that best describe the level of discomfort on a scale of 1 to 10.

1. Slight awareness of discomfort.
2-3. Awareness of discomfort as an aggravation.
4-6. Pain is strong but you are still functional.
7-9. Pain is so strong you are unable to function normally.
10. You feel like you need to go to the emergency room.

Please shade areas of pain or discomfort on the body diagrams and make comments on the side if necessary.

COMMENTS

Practitioner’s comments:

Client Signature:

Practitioner Signature:

Date

Acceptance

I agree payment is due at time of service as time has been especially reserved for me