Name
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First Name
Last Name
Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Gender
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Birth Gender
Approximate Height/Weight
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Primary reason for seeking care
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Please list a brief description of chief complaint(s)
Please list any serious accidents, surgeries and hospitalizations
Do you have any direct family history of cardiocascular disease (stroke, hypertension, heart disease etc) cancer, diabetes, autoimmune disease, or significant depression?
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Have you ever been diagonosed with cancer, heart disease, hypertension, seizure disorders/neurological disease, thyroid disease, or automimmune disease?
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If no, please type no. If yes, please explain
Are you currently under the care of a physician and receiving prescription medications?
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Please describe your current energy levels, 1 is very low energy, 10 is very high. State what time of day are you most/least energetic
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What is the typical time you wake up/go to bed each day?
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Please describe your typical breakfast/morning food/liquid
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Please describe your typical lunch
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Please describe your typical dinner
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Do you snack frequently? If so, what do you snack on?
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Please list if you have any of the following GI symptoms
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Please describe average bowel movements
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Understanding the bowel habit is critical to understanding the patient's gastrointestinal function.
Please list if you have any of these urinary symptoms
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Eyes/Ears/Nose
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Cardiopulmonary
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Musculoskeletal
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Please describe any orthopedic (bone, muscle and joint) issues/history you would like me to know about. Please include significant past events, such as accidents. What makes your orthopedic pain better/worse? (Ex: movement vs, rest, warmth vs, cold)
Reproductive Health
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Exercise
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Please describe any exercise routines you engage from a weekly perspective.
Emotional Health
Emotional health and physical health are intimately connected. Please describe any significant past or current sources of stress, any depression, or other emotional events.
What do you do for self care?
Please describe if you have a self care practice.
Women: Menstrual characteristics
Please describe the characteristics of your cycle. If you do not get a cycle now, please list how it used to be.
Women: Peri/Post Menopause
Please list if you have any of these symptoms
Other
Please list any other health history not addressed in this questionaire