PERSONAL INFORMATION + MEDICAL HISTORY
First Name
Last Name
Home Address
Address (Line 2)
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
Home Phone
Cell Phone
E-mail
Date of Birth
-
Month
-
Day
Year
Date
Height
Weight
Describe your PRINCIPAL COMPLAINT:
DIAGNOSIS received by another physician:
[CHILDHOOD]
Any birth trauma? If so, describe:
Any childhood illness, surgeries or accidents?
incident 1 description and age
incident 2 description and age
[ADOLESCENCE]
Any illnesses, surgeries or accidents during adolescence?
incident 1 description and age
incident 1 description and age
incident 1 description and age
[ADULTHOOD]
Any illnesses, surgeries or accidents as an adult?
incident 1 description and age
incident 2 description and age
incident 3 description and age
incident 4 description and age
incident 5 description and age
Please note all major ILLNESSES in your immediate family, such as diabetes, heart disease, blood pressure, neurological disorders, physchological disorders, blood disorders, orthopaedic disorders:
Are you taking any MEDICATION? Please list all medication, herbs, vitamins and minerals you take, even if taken only occasionally.
Do you have any SCARS? Note location of all operation or injury scars {even minor ones}.
SYMPTOM LIST
Please check to indicate any problem, disease or symptom you have presently or have experienced in the past.
SKIN
eczema
present
past
acne
present
past
skin rashes
present
past
dermatis
present
past
furuncles
present
past
fungal infections
present
past
warts
present
past
psoriasis
present
past
HEART + VASCULAR
fast pulse [>100 beats/minute]
present
past
slow pulse
present
past
palpitation
present
past
irregular pulse
present
past
feeling pressure in the chest
present
past
short of breath
present
past
chest pain
present
past
dizzyness
present
past
migraine headache with nausea
present
past
cold hands/feet
present
past
Raynaud"s disease
present
past
flushed face
present
past
high blood pressure
present
past
low blood pressure
present
past
anemia
present
past
cold sweats
present
past
red face
present
past
feel dizzy or faint when standing up quickly or standing for a long time
present
past
GASTROINTESTINAL
constipation
present
past
diarrhea
present
past
no appetite
present
past
stomach pain
present
past
indigestion
present
past
heartburn
present
past
intestinal gas
present
past
belching
present
past
ulcer
present
past
gastritis
present
past
lack of stomach acid
present
past
hemorrhoids
present
past
Other
peritonitis
present
past
pancreatitis
present
past
irritable bowel
present
past
polyps
present
past
GI tumors
present
past
HORMONAL IMBALANCE
low thyroid
present
past
overactive thyroid
present
past
diabetes
present
past
hypoglycemia
present
past
blood sugar
present
past
other hormonal imbalance
present
past
RESPIRATORY
asthma
present
past
lung abscess
present
past
bronchitis
present
past
emphysema
present
past
cough
present
past
wheezing
present
past
pneumonia
present
past
AUTOIMMUNE + INFLAMMATORY CONDITIONS
Hashimoto"s disease
present
past
colitis
present
past
rheumatism
present
past
Crohn"s disease
present
past
systemic lupus erythematosus
present
past
alopecia [baldness]
present
past
allergy
present
past
food allergy
present
past
atopic dermatitis
present
past
neurodermatitis
present
past
cellulitis
present
past
sinus allergy
present
past
vulvitis
present
past
low immunity
present
past
EFFECTS OF FOCAL INFECTIONS
rheumatic disease
present
past
arthritis
present
past
rheumatic fever
present
past
skin disease
present
past
MALE
impotence
present
past
infertility
present
past
premature ejaculation
present
past
vasectomy
present
past
prostate gland problem
present
past
FEMALE
menstrual problems
present
past
cramping
present
past
heavy/light/irregular periods
present
past
PMS
present
past
emotional reactions
present
past
menopause symptoms
present
past
tubal ligation
present
past
infertility
present
past
low libido
present
past
CONNECTIVE TISSUE OR LIGAMENT DISEASE
myofascial pain syndrome
present
past
fibromyalgia
present
past
tendinitis
present
past
ligament issues
present
past
pericarditis
present
past
constant slight fever
present
past
glomerulonephritis
present
past
plantar fasciitis
present
past
scarlet fever
present
past
streptococcal infections
present
past
EAR, NOSE + THROAT
easily catch cold
present
past
swollen glands
present
past
deafness
present
past
ear pain
present
past
itchy ear
present
past
tinnitus [ringing in ear]
present
past
frequent ear infections
present
past
sinus headaches
present
past
yellow mucus
present
past
stuffy nose
present
past
post-nasal-drip
present
past
dry throat
present
past
itchy throat
present
past
constant sinus congestion
present
past
streptococcal infections
present
past
sore throat
present
past
GENERAL
insomnia
present
past
no appetite for breakfast
present
past
psychosomatic weakness
present
past
moody in mornings
present
past
exhaustion
present
past
unusual sweating [palm, sole or elsewear]
present
past
emotional problems [angry, irritable, depressed, anxious]
present
past
never sweat
present
past
difficulty concentrating on a task
present
past
easily get car sick, sea sick, or air sick
present
past
GENERAL | BEFORE NOON
no energy
present
past
feel spacey
present
past
scattered minded
present
past
energetic all evening through midnight, but hate to wake up early in the morning
present
past
long shower or bath makes you feel dizzy or faint
present
past
MEDICATION + DRUGS
birth control pills
present
past
cigarettes
present
past
alcohol
present
past
cocaine
present
past
marijuana
present
past
LIST OTHER SYMPTOMS
Submit
Should be Empty: