Medical History Form HEALTH HISTORY First Name: Middle Initial: Last Name: Gender: Male Female Date of Birth: From whom are you currently receiving health care? What, if any, contagious disease do you have at this time? What childhood illnesses have you had?What allergies to drugs or food do you have?What current medications do you take and for what?List vitamins/supplements you are currently taking.YOUR MEDICAL HISTORY:Chronic or continuing illnesses: Surgeries, major illnesses, hospitalizations, and major accidents (include year):History of Childhood Trauma? Yes No Are you a former smoker? Yes No How many packs per day? Are you a current smoker? Yes No How many packs per day? What was your last blood pressure reading? What is your normal body temperature reading? FAMILY HISTORY:Age (if living) Father: Mother: Brother(s): Sister(s): Child(ren): Health (G=good P=poor) Father: Mother: Brother(s): Sister(s): Child(ren): WHAT BRINGS YOU HERE TODAY? What is the reason for your visit today? How, when, and where did this condition begin? What types of treatments have you tried, if any? How does this condition impair your daily activities? SYSTEMS REVIEW (Please select all that apply)0=Never 1=rarely 2=occasionally 3=frequently 4=alwaysGROUP 1 Sympathetic Dominance 0 1 2 3 4 Acid foods upset 0 1 2 3 4 Get chilled often 0 1 2 3 4 "Lump" in throat 0 1 2 3 4 Dry mouth-eyes-nose 0 1 2 3 4 Pulse speeds after meal 0 1 2 3 4 Keyed up - fail to calm 0 1 2 3 4 Cut heals slowly 0 1 2 3 4 Gag easily 0 1 2 3 4 Unable to relax; startles easily 0 1 2 3 4 Extremities cold, clammy 0 1 2 3 4 Strong light irritates 0 1 2 3 4 Urine amount reduced 0 1 2 3 4 Heart pounds after retiring 0 1 2 3 4 "Nervous" stomach 0 1 2 3 4 Appetite reduced 0 1 2 3 4 Cold sweats often 0 1 2 3 4 Fever easily raised 0 1 2 3 4 Neuralgia-like pains 0 1 2 3 4 Staring, blinks little 0 1 2 3 4 Sour stomach oftenGROUP 2 Parasympathetic Dominance 0 1 2 3 4 Joint stiffness on arising 0 1 2 3 4 Muscle-leg-toe cramps at night 0 1 2 3 4 "Butterfly" stomach, cramps 0 1 2 3 4 Eyes or nose watery 0 1 2 3 4 Eyes blink often 0 1 2 3 4 Eyelids swollen, puffy 0 1 2 3 4 Indigestion soon after meals 0 1 2 3 4 Always seems hungry; feels "lightheaded" often 0 1 2 3 4 Digestion rapid 0 1 2 3 4 Vomiting frequent 0 1 2 3 4 Hoarseness frequent 0 1 2 3 4 Breathing irregular 0 1 2 3 4 Pulse slow; feels "irregular" 0 1 2 3 4 Gagging reflex slow 0 1 2 3 4 Difficulty swallowing 0 1 2 3 4 Constipation, diarrhea alternating 0 1 2 3 4 "Slow starter" 0 1 2 3 4 Get "chilled" infrequently 0 1 2 3 4 Perspire easily 0 1 2 3 4 Circulation poor, sensitive to cold 0 1 2 3 4 Subject to colds, asthma, bronchitisGROUP 3 Sugar Handling 0 1 2 3 4 Eat when nervous 0 1 2 3 4 Excessive appetite 0 1 2 3 4 Hungry between meals 0 1 2 3 4 Irritable before meals 0 1 2 3 4 Get "shaky" if hungry 0 1 2 3 4 Fatigue, eating relieves 0 1 2 3 4 "Lightheaded" if meals delayed 0 1 2 3 4 Heart palpitates if meals missed or delayed 0 1 2 3 4 Afternoon headaches 0 1 2 3 4 Overeating sweets upsets 0 1 2 3 4 Awaken after few hours sleep - hard to get back to sleep 0 1 2 3 4 Crave candy or coffee in afternoons 0 1 2 3 4 Moods of depression - "blues" or melancholy 0 1 2 3 4 Abnormal craving for sweets or snacksGROUP 4 Cardiovascular 0 1 2 3 4 Hands and feet go to sleep easily, numbness 0 1 2 3 4 Sigh frequently, "air hunger" 0 1 2 3 4 Aware of "breathing heavily" 0 1 2 3 4 High altitude discomfort 0 1 2 3 4 Opens windows in closed rooms 0 1 2 3 4 Susceptible to colds and fevers 0 1 2 3 4 Afternoon "yawner" 0 1 2 3 4 Get "drowsy" often 0 1 2 3 4 Swollen ankles, worse at night 0 1 2 3 4 Muscle cramps, worse during exercise; get "charley horses" 0 1 2 3 4 Shortness of breath on exertion 0 1 2 3 4 Dull pain in chest or radiating into left arm, worse on exertion 0 1 2 3 4 Bruise easily, "black and blue" spots 0 1 2 3 4 Tendency to anemia 0 1 2 3 4 "Nose bleeds" frequent 0 1 2 3 4 Noises in head, or "ringing in ears" 0 1 2 3 4 Tension under the breastbone, or feeling of "tightness", worse on exertionGROUP 5 Billiary and Liver 0 1 2 3 4 Dizziness 0 1 2 3 4 Dry skin 0 1 2 3 4 Burning feet 0 1 2 3 4 Blurred vision 0 1 2 3 4 Itching skin and feet 0 1 2 3 4 Excessive falling hair 0 1 2 3 4 Frequent skin rashes 0 1 2 3 4 Bitter, metallic taste in mouth in mornings 0 1 2 3 4 Bowel movements painful or difficult 0 1 2 3 4 Worrier, feels insecure 0 1 2 3 4 Feeling queasy; headache over eyes 0 1 2 3 4 Greasy foods upset 0 1 2 3 4 Stools light colored 0 1 2 3 4 Skin peels on foot soles 0 1 2 3 4 Pain between shoulder blades 0 1 2 3 4 Use laxatives 0 1 2 3 4 Stools alternate from soft to watery 0 1 2 3 4 History of gallbladder attacks or gallstones 0 1 2 3 4 Sneezing attacks 0 1 2 3 4 Dreaming, nightmare type bad dreams 0 1 2 3 4 Bad breath (halitosis) 0 1 2 3 4 Milk products cause distress 0 1 2 3 4 Sensitive to hot weather 0 1 2 3 4 Burning or itching anus 0 1 2 3 4 Crave sweetsGROUP 6 Digestive 0 1 2 3 4 Loss of taste for meat 0 1 2 3 4 Lower bowel gas several hours after eating 0 1 2 3 4 Burning stomach sensations, eating relieves 0 1 2 3 4 Coated tongue 0 1 2 3 4 Pass large amounts of foul-smelling gas 0 1 2 3 4 Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs . 0 1 2 3 4 Mucous colitis or "irritable bowel" 0 1 2 3 4 Gas shortly after eating 0 1 2 3 4 Stomach "bloating" after eatingGROUP 7A Hyperthyroid 0 1 2 3 4 Insomnia 0 1 2 3 4 Nervousness 0 1 2 3 4 Can't gain weight 0 1 2 3 4 Intolerance to heat 0 1 2 3 4 Highly emotional 0 1 2 3 4 Flush easily 0 1 2 3 4 Night sweats 0 1 2 3 4 Thin, moist skin 0 1 2 3 4 Inward trembling 0 1 2 3 4 Heart palpitates 0 1 2 3 4 Increased appetite without weight gain 0 1 2 3 4 Pulse fast at rest 0 1 2 3 4 Eyelids and face twitch 0 1 2 3 4 Irritable and restless 0 1 2 3 4 Can't work under pressureGROUP 7B Hypothyroid 0 1 2 3 4 Increase in weight 0 1 2 3 4 Decrease in appetite 0 1 2 3 4 Fatigue easily 0 1 2 3 4 Ringing in ears 0 1 2 3 4 Sleepy during day 0 1 2 3 4 Sensitive to cold 0 1 2 3 4 Dry or scaly skin 0 1 2 3 4 Constipation 0 1 2 3 4 Mental sluggishness 0 1 2 3 4 Hair coarse, falls out 0 1 2 3 4 Headaches upon arising, wear off during day 0 1 2 3 4 Slow pulse, below 65 0 1 2 3 4 Frequency of urination 0 1 2 3 4 Impaired hearing 0 1 2 3 4 Reduced initiativeGROUP7C Hyperpituitary 0 1 2 3 4 Failing memory 0 1 2 3 4 Low blood pressure 0 1 2 3 4 Increased sex drive 0 1 2 3 4 Headaches, "splitting or rending" type 0 1 2 3 4 Decreased sugar toleranceGROUP7D Hypopituitary 0 1 2 3 4 Abnormal thirst 0 1 2 3 4 Bloating of abdomen 0 1 2 3 4 Weight gain around hips or waist 0 1 2 3 4 Sex drive reduced or lacking 0 1 2 3 4 Tendency to ulcers, colitis 0 1 2 3 4 Increased sugar tolerance 0 1 2 3 4 Women: menstrual disorders 0 1 2 3 4 Young girls: lack of menstrual functionGROUP 7E Hyperadrenal 0 1 2 3 4 Dizziness 0 1 2 3 4 Headaches 0 1 2 3 4 Hot flashes 0 1 2 3 4 Increased blood pressure 0 1 2 3 4 Hair growth on face or body (female) 0 1 2 3 4 Sugar in urine (not diabetes) 0 1 2 3 4 Masculine tendencies (female)GROUP 7F Hypoadrenal 0 1 2 3 4 Weakness, dizziness 0 1 2 3 4 Chronic fatigue 0 1 2 3 4 Low blood pressure 0 1 2 3 4 Nails weak, ridged 0 1 2 3 4 Tendency to hives 0 1 2 3 4 Arthritic tendencies 0 1 2 3 4 Perspiration increase 0 1 2 3 4 Bowel disorders 0 1 2 3 4 Poor circulation 0 1 2 3 4 Swollen ankles 0 1 2 3 4 Crave salt 0 1 2 3 4 Brown spots or bronzing of skin 0 1 2 3 4 Allergies - tendency to asthma 0 1 2 3 4 Weakness after colds, influenza 0 1 2 3 4 Exhaustion - muscular and nervous 0 1 2 3 4 Respiratory disordersGROUP 8 Complex Deficiencies 0 1 2 3 4 Muscle weakness 0 1 2 3 4 Lack of Stamina 0 1 2 3 4 Drowsiness after eating 0 1 2 3 4 Muscular soreness 0 1 2 3 4 Rapid heart beat 0 1 2 3 4 Hyper-irritable 0 1 2 3 4 Feeling of a band around your head 0 1 2 3 4 Melancholia (feeling of sadness) 0 1 2 3 4 Swelling of ankles 0 1 2 3 4 Diminished urination 0 1 2 3 4 Tendency to consume sweets or carbohydrates 0 1 2 3 4 Muscle spasms 0 1 2 3 4 Blurred vision 0 1 2 3 4 Loss of muscular control 0 1 2 3 4 Numbness 0 1 2 3 4 Night sweats 0 1 2 3 4 Rapid digestion 0 1 2 3 4 Sensitivity to noise 0 1 2 3 4 Redness of palms of hands and bottom of feet 0 1 2 3 4 Visible veins on chest and abdomen 0 1 2 3 4 Hemorrhoids 0 1 2 3 4 Apprehension (feeling that something bad will happen) 0 1 2 3 4 Nervousness causing loss of appetite 0 1 2 3 4 Nervousness with indigestion 0 1 2 3 4 Gastritis 0 1 2 3 4 Forgetfulness 0 1 2 3 4 Thinning hairFEMALE ONLY 0 1 2 3 4 Very easily fatigued 0 1 2 3 4 Premenstrual tension 0 1 2 3 4 Painful menses 0 1 2 3 4 Depressed feelings before menstruation 0 1 2 3 4 Menstruation excessive and prolonged 0 1 2 3 4 Painful breasts 0 1 2 3 4 Menstruate too frequently 0 1 2 3 4 Vaginal discharge 0 1 2 3 4 Hysterectomy / ovaries removed 0 1 2 3 4 Menopause hot flashes 0 1 2 3 4 Menses scanty or missed 0 1 2 3 4 Acne, worse at menses 0 1 2 3 4 Depression of long standingMALE ONLY 0 1 2 3 4 Prostate trouble 0 1 2 3 4 Urination difficult or dribbling 0 1 2 3 4 Night urination frequent 0 1 2 3 4 Depression 0 1 2 3 4 Pain on inside of legs or heels 0 1 2 3 4 Feeling of incomplete bowel evacuation 0 1 2 3 4 Lack of energy 0 1 2 3 4 Migrating aches and pains 0 1 2 3 4 Tire too easily 0 1 2 3 4 Avoids activity 0 1 2 3 4 Leg nervousness at night 0 1 2 3 4 Diminished sex driveWOMEN ONLY:At what age did you get your first period: Date of last menstrual cycle: Are you currently on birth control? Yes No If yes, what kind? Are you pregnant now? Yes No Number of days from the start of one period to the start of the next: Average number of days of flow: Are your menstrual cycles spaced regularly? Yes No Flow is: Light Normal Heavy Color is: Light Red Red Dark Red Purple Brown Do you have blood clots? Yes No Does you period cause you pain or cramping? Yes No If yes, when? Before During After period Fibrocystic breasts? Yes No Do you experience any of the following before your period each month? Water retention Breast tenderness or swelling Mental depression Irritability Food cravings Migraines Other Number of pregnancies: Number of abortions: Number of live births: Number of miscarriages: Are you in menopause? Yes No When? MEN ONLY: Have you been diagnosed with prostate problems? Yes No Have you been diagnosed with infertility? Yes No Thank you for taking the time to fill out this form as completely as possible. 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