Health History

Patient Health History Intake Form

Today's Date:
Last Name: *
First Name: *
Address:
City:
State:
Zipcode:
Email: *
Phone:
Gender at Birth:
Your Gender Pronouns:
Relationship Status:
Birth Date:
Number of Children:

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

Describe the areas of your health that you would like to see improvement in, from most troublesome to least. Please include dates when each issue occurred.

Health Issue:
Date of Onset:
Past Medical History (previous injuries, accidents, surgeries, etc.) Please describe and include approximate dates:
Medications you are currently taking (including over the counter, herbal or homeopathic):
Please list any medical tests you have had within the past year:
What is your history of taking antibiotics:
Please describe any daily activities you are finding dificulties or are limited because of your above complaints:
What are your goals for mind-body-spirit wellness?:
Check the feelings that you have experienced in the last few months:
Abused
Criticized
Overworked
Paralyzed
Depressed
Rejected
Despair
Helpless
Hopeless
Paranoid
Overwhelmed
Muddled
Persecuted
Guilty
Easilly Irritated
Anxious
Sad
Grieving
Unable to Grieve
Apprehensive
Agitated
Uneasy
Distress
Fearful
Impatient
Imtimidated
Restless
Panic
Intolerant
Uncertainty
Aggravated
Annoyed
Angry
Outraged
Nervous
Worried

Indicate your areas and levels of stress below.

Family Stress:
None
Minimal
Moderate
Severe
Relationship Stress:
None
Minimal
Moderate
Severe
Work Stress:
None
Minimal
Moderate
Severe
Financial Stress:
None
Minimal
Moderate
Severe
Health Stress:
None
Minimal
Moderate
Severe
Other Stress:
None
Minimal
Moderate
Severe
How much time do you have for yourself to relax and what do you do to relax, i.e. hobbies, meditation, etc? Do you excercise? And if so, what kind and how often:
How many hours a night do you sleep? Is your sleep restful? If not, please explain:
Have you had past experiences that still effect you deeply (trauma, accident, grief, vaccine, illness, etc):
List your areas of pain (i.e. right shoulder, left ankle/front/side etc.) and rate the severity of pain 1-5 using the following scale. 1 - slight awareness of discomfort, 2 - awareness of discomfort as an aggravation, 3 - Pain strong but you are still functional, 4 - Pain is so strong that you are unable to function normally, 5 - pain so severe that you feel like you must go to the emergency room:

Rate your lifestyle health habbits in each category using the following scale. 1 - Unhealthy, 2 - Not Very Healthy, 3 - Somewhat Healthy, 4 - Mostly Healthy, 5 - Very Healthy

Nutrition:
0 5
Exercise:
0 5
Sleep:
0 5
Stress Management:
0 5
Toxic Load:
0 5
Self Care:
0 5
Medical Care:
0 5
Submit