Health Questionnaire & Self-Assessment Name First Last Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail Birth Date MM slash DD slash YYYY AgeGenderGenderMaleFemalePrefer Not to AnswerWeight Height Family Physician Family Physician PhoneCurrent Occupation Briefly list health problems and symptoms of concern:Current diagnosis: List the medications you are presently on:MedicationReason List the supplements you are presently on: List the surgeries and year:SurgeryYearMedicationReason List any allergies (foods, chemicals, pollens, etc.)Please explain your health concerns.The more details you include, the better we will be able to evaluate your needs, Please include any previous treatments and their effectiveness.Group 1 Gas/indigestion Heartburn Diarrhea Undigested food in stool Stomach feels bloated after eating Have or had ulcers Bad breath Tired/sleepy after eating Foul smelling gas or stool Number of times bowl movements per day*Group 2 Colds/flu per year Sinus problems Swollen lymph nodes Fatty tumors Sore throats per year Boils or pimples Mucus in eyes in morning Snoring Tonsils removed Catch everything that comes around A lot of mucus in throat Breast lumps Re-occurring pneumonia Re-occurring bronchitis Pain when breathing Cough a lot Mucus when you cough Number of colds/flu per year*1234567891011121314151617181920Tonsils removed on what age* Color of mucus when you cough* Group 3 Rectal itching Teeth grinding at night Vaginal itching or discharge Ear itching Itching skin rash White-coated tongue Fatigue/low energy Brain fog Hungry all the time Unexpected weight loss Group 4 Mid-lower back pain Burning felling when urinating Have or had kidney stones Bags under eyes (especially mornings) Problems holding your bladder Urine flow restricted Pain center-lower stomach Frequent urination Prolapsed bladder Group 5 Pain under right lower rib Tightness between shoulder blades Discomfort from greasy foods Tired spells Rash Dark brown skin spots Other skin problems Problem sleeping between 1 & 3 a.m. Chemical sensitivity Sensitivity to strong odors Describe Rash* Include PhotoMax. file size: 2 MB.Details of other skin problems* Group 6 Shortness of breath when using stairs Chest and left shoulder pain Cold hands and feet Chest pressure Dizziness Irregular heartbeat High blood pressure Varicose/spider veins Hemorrhoids Bruise easily Leg, feet or hand numbness Poor memory Systolic over Diastolic* Group 7 Muscle pain Joint pain Other pain Detail of other pain (e.g. where)* Group 8 Cold hands and feet Dry hair or skin Easy to gain weight but hard to lose it Ridged, brittle or weak nails Rapid heartbeat while resting Migraines or headaches Overweight List energy level 1-10 (10 being the best) List stress level 1-10 (10 being the highest) Depression Anxiety Irritable Unexplained crying spells Anxious and edgy Low motivation Problem falling asleep Problem staying asleep Low blood pressure Get dizzy when standing up List energy level (1-10)* List stress level (1-10)* Systolic over Diastolic* Group 9 Ovarian cysts/fibroids Hysterectomy Infertility Miscarriage Irregular menstruation Hot flashes/night sweats Please describe irregular menstration* Group 10 Frequent urination at night Prostate cancer PSA (write #) Erection problems Incontinence