Preview Medical History

First Name:
Middle Initial:
Last Name:
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.
Chronic or continuing illnesses:
Surgeries, major illnesses, hospitalizations, and major accidents (include year):
History of Childhood Trauma?
Are you a former smoker?
How many packs per day?
Are you a current smoker?
How many packs per day?
What was your last blood pressure reading?
What is your normal body temperature reading?
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 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=always
GROUP 1 Sympathetic Dominance
Acid foods upset
Get chilled often
"Lump" in throat
Dry mouth-eyes-nose
Pulse speeds after meal
Keyed up - fail to calm
Cut heals slowly
Gag easily
Unable to relax; startles easily
Extremities cold, clammy
Strong light irritates
Urine amount reduced
Heart pounds after retiring
"Nervous" stomach
Appetite reduced
Cold sweats often
Fever easily raised
Neuralgia-like pains
Staring, blinks little
Sour stomach often
GROUP 2 Parasympathetic Dominance
Joint stiffness on arising
Muscle-leg-toe cramps at night
"Butterfly" stomach, cramps
Eyes or nose watery
Eyes blink often
Eyelids swollen, puffy
Indigestion soon after meals
Always seems hungry; feels "lightheaded" often
Digestion rapid
Vomiting frequent
Hoarseness frequent
Breathing irregular
Pulse slow; feels "irregular"
Gagging reflex slow
Difficulty swallowing
Constipation, diarrhea alternating
"Slow starter"
Get "chilled" infrequently
Perspire easily
Circulation poor, sensitive to cold
Subject to colds, asthma, bronchitis
GROUP 3 Sugar Handling
Eat when nervous
Excessive appetite
Hungry between meals
Irritable before meals
Get "shaky" if hungry
Fatigue, eating relieves
"Lightheaded" if meals delayed
Heart palpitates if meals missed or delayed
Afternoon headaches
Overeating sweets upsets
Awaken after few hours sleep - hard to get back to sleep
Crave candy or coffee in afternoons
Moods of depression - "blues" or melancholy
Abnormal craving for sweets or snacks
GROUP 4 Cardiovascular
Hands and feet go to sleep easily, numbness
Sigh frequently, "air hunger"
Aware of "breathing heavily"
High altitude discomfort
Opens windows in closed rooms
Susceptible to colds and fevers
Afternoon "yawner"
Get "drowsy" often
Swollen ankles, worse at night
Muscle cramps, worse during exercise; get "charley horses"
Shortness of breath on exertion
Dull pain in chest or radiating into left arm, worse on exertion
Bruise easily, "black and blue" spots
Tendency to anemia
"Nose bleeds" frequent
Noises in head, or "ringing in ears"
Tension under the breastbone, or feeling of "tightness", worse on exertion
GROUP 5 Billiary and Liver
Dry skin
Burning feet
Blurred vision
Itching skin and feet
Excessive falling hair
Frequent skin rashes
Bitter, metallic taste in mouth in mornings
Bowel movements painful or difficult
Worrier, feels insecure
Feeling queasy; headache over eyes
Greasy foods upset
Stools light colored
Skin peels on foot soles
Pain between shoulder blades
Use laxatives
Stools alternate from soft to watery
History of gallbladder attacks or gallstones
Sneezing attacks
Dreaming, nightmare type bad dreams
Bad breath (halitosis)
Milk products cause distress
Sensitive to hot weather
Burning or itching anus
Crave sweets
GROUP 6 Digestive
Loss of taste for meat
Lower bowel gas several hours after eating
Burning stomach sensations, eating relieves
Coated tongue
Pass large amounts of foul-smelling gas
Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs .
Mucous colitis or "irritable bowel"
Gas shortly after eating
Stomach "bloating" after eating
GROUP 7A Hyperthyroid
Can't gain weight
Intolerance to heat
Highly emotional
Flush easily
Night sweats
Thin, moist skin
Inward trembling
Heart palpitates
Increased appetite without weight gain
Pulse fast at rest
Eyelids and face twitch
Irritable and restless
Can't work under pressure
GROUP 7B Hypothyroid
Increase in weight
Decrease in appetite
Fatigue easily
Ringing in ears
Sleepy during day
Sensitive to cold
Dry or scaly skin
Mental sluggishness
Hair coarse, falls out
Headaches upon arising, wear off during day
Slow pulse, below 65
Frequency of urination
Impaired hearing
Reduced initiative
GROUP7C Hyperpituitary
Failing memory
Low blood pressure
Increased sex drive
Headaches, "splitting or rending" type
Decreased sugar tolerance
GROUP7D Hypopituitary
Abnormal thirst
Bloating of abdomen
Weight gain around hips or waist
Sex drive reduced or lacking
Tendency to ulcers, colitis
Increased sugar tolerance
Women: menstrual disorders
Young girls: lack of menstrual function
GROUP 7E Hyperadrenal
Hot flashes
Increased blood pressure
Hair growth on face or body (female)
Sugar in urine (not diabetes)
Masculine tendencies (female)
GROUP 7F Hypoadrenal
Weakness, dizziness
Chronic fatigue
Low blood pressure
Nails weak, ridged
Tendency to hives
Arthritic tendencies
Perspiration increase
Bowel disorders
Poor circulation
Swollen ankles
Crave salt
Brown spots or bronzing of skin
Allergies - tendency to asthma
Weakness after colds, influenza
Exhaustion - muscular and nervous
Respiratory disorders
GROUP 8 Complex Deficiencies
Muscle weakness
Lack of Stamina
Drowsiness after eating
Muscular soreness
Rapid heart beat
Feeling of a band around your head
Melancholia (feeling of sadness)
Swelling of ankles
Diminished urination
Tendency to consume sweets or carbohydrates
Muscle spasms
Blurred vision
Loss of muscular control
Night sweats
Rapid digestion
Sensitivity to noise
Redness of palms of hands and bottom of feet
Visible veins on chest and abdomen
Apprehension (feeling that something bad will happen)
Nervousness causing loss of appetite
Nervousness with indigestion
Thinning hair


Thank you for taking the time to fill out this form as completely as possible. Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient’s physical, mental and emotional state.

Patient's Name: