Health Questionnaire and Self-Assessment

Name

Address

Phone Number

Email

Birth Date

Age

Gender

Weight

Height

Family Physician

Family Physician Phone

Current Occupation

Briefly list health problems and symptoms of concern:

Current diagnosis:

List the medications you are presently on:

Medication	Reason

List the supplements you are presently on:

List the surgeries and year:

Surgery	Year	Medication	Reason

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

Number of colds/flu per year*

Tonsils removed on what age*

Color of mucus when you cough*

Group 3

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

Describe Rash*

Include Photo

Max. file size: 2 MB.

Details of other skin problems*

Group 6

Systolic over Diastolic*

Group 7

Muscle pain
Joint pain
Other pain

Detail of other pain (e.g. where)*

Group 8

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

Health Questionnaire & Self-Assessment

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