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Name________________________________________________Date_____________________________
Male___ Female____ Age____ Married____ Divorced____ Single____ Date of birth:_________________
occupation__________________________________ Referred by:_________________________________
Mailing Address:________________________________________________________________________
Email Address:_________________________ Emergency Contact and #:___________________________
Home Phone:_______________Cell Phone/other:_________________Physician:_____________________
Chief Complaint:_______________________________________________________________________
Date of Onset___________________
Current Medications: _____________________________________________________________________________________
Other Concurrent Therapies & Dr.Name & #________________________________________________
_____________________________________________________________________________________
Allergies(drugs, chemicals, food)___________________________________________________________
NOW:( )Pregnant ( )Pacemaker ( )Aids ( )Hepatitis ( )Blood Transfusions ( )Implants/Artificial parts
Past Medical History/Illnesses: (include date)
__Arthritis __Asthma __Auto Immune Disease __Alcoholism __Bronchitis __Cancer
__Chronic Fatigue Syndrome __Chronic Lung Disease __Diabetes/Hypoglycemia __Drugs __Heart Disease
__Hepatitis __Hernia __High Blood Pressure __Kidney Disease
__Organ Transplant __Pneumonia __Rheumatic Fever __Seizures/Epilepsy
__Sexually Transmitted Diseases(STD) __Thyroid Disease __Tuberculosis
__Ulcers __Vaccine Reaction __Whooping Cough
Surgeries:_____________________________________________________________________________
Significant Trauma(auto Accidents, falls, etc)________________________________________________
Occupational Stresses(chemical, physical, Psychological, etc)
exercise:
Habits: __Cigarettes __Coffee __tea __Cola __Alcohol __drugs __sugar __Salt __Other___________
Family medical history: __Diabetes __cancer __High blood pressure __Heart disease __Stroke __Seizures __Asthma
__Allergies __Alcoholism __Other¬¬¬¬¬¬¬¬_______________
GENERAL (Check all that apply now!)
__Poor appetite __Heavy appetite __Poor sleep __Heavy sleep
__Insomnia __Fatigue __Tremors __Vertigo
__cold hands __cold feet __cold back __cold
abdomen
__Fevers __chills __night sweats
__sweat easily
__cravings __localized weakness __poor coordination __ change in appetite
__sudden energy drop at_____a.m._____p.m. __peculiar tastes/smells______________________
__Strong thirst(cold/hot drinks)________________ __bleed or bruise easily(where)_________________
SKIN
__Rashes __Ulcerations __Hives
__Itching
__Eczema __Pimples __ dandruff
__Loss of hair
__Change in hair/skin texture __ purpura __other hair or skin
Other Problems with skin :
(whether it appears related or not to your reason for visit)
HEAD, EYES, EARS, NOSE, AND THROAT
__Dizziness __Concussions __ Migraines __Glasses
__Eye strain __Eye pain __Poor vision __Night
blindness
__Color blindness __Cataracts __Blurry vision __Earaches
__Ringing in ears __Poor hearing __Nose bleeds __Sinus problems
__Mucus __Dry throat __Dry mouth __Copius
saliva
__Teeth problems __Jaw clicks __Grinding teeth __Facial pain
__Gum problems __Spots in eyes __Recurrent sore Throats__________/Month
__Sores on lips or tongue __Headaches(where and when)_________________
__Other head or neck problems________________________________________________________________________________________
CARDIOVASCULAR
__High blood pressure __Low blood pressure __Chest pain __ Irregular
heartbeat
__Dizziness __ Fainting __Cold hand/feet
__Swelling in hands/feet
__Blood clots __Phlebitis __Difficulty breathing
__other ¬¬¬¬¬¬¬¬¬¬¬¬¬¬________________
GASTROINTESTINAL
__Gas __ Belching __Bad breath
__Intestinal Pain or cramps
__Sensitive Abdomen __Rectal pain __Bloody stools __ Black
stool
__Bowel movement: __________Frequency _____________Color ____________Odor __________Texture/form
__Diarrhea __Constipation __Hemorrhoids
__Laxative use:____/week;type_____________
RESPIRATORY
__Cough __Coughing blood __Breathing difficult __Wheezing
__Sneezing __Chest/ribs hurt __Coughing/Mucus
GENITO-URINARY
__Pain on urination __Frequent urination __Blood in urine __Urgency
to urinate
__Unable to hold urine __Kidney stones __Venereal disease __Impotency
__Wake up to urinate; how often___________/night; time:_______________________
PREGNACY AND GYNOCOLOGY
Number pregnancies_________ Number births________ Premature births ________ Miscarriages________
Age at first menses__________ Period(cycle days)________ Duration________/mo. __ Irregular periods
each month do your periods; __start early __Start on time __start late
Flow(describe)______________________________ __Clotting Last PAP_________ Last menses________________
Vaginal Discharge, color________ __Vaginal sores __Breast lumps __Menopause
Birth control Type & duration ____________________________________________________________________
MUSCULOSKELETAL
__Neck pain __Muscle pain __Back pain __Joint pain(where)___________________
__Other joint or bone problems______________________________________________________________________
______________________________________________________________________________________________
NEUROPSYCHOLOGICAL
__Seizures __Areas of numbness __Poor memory __Concussion
__Depression __Anxiety __Bad temper __Easily
stressed
__Treated for emotional problems __Considered or attempted suicide
Other neurological or psychological problems? ________________________________________________________
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