Health Inventory
This information is confidential and will only be released with your signed consent.
Please use as much space as needed for your responses.
Date:
Name:
Date of Birth: Age:
If under age 18, parent name and address:
Sex: Male/Female/Other
Address (street, city, state, zip):
Phone (c): (h):
E-mail:
Marital status: Single/Married/Divorced/Separated/Widowed.
Education (highest completed):
Occupation (Nature of work):
Retired: Yes/No
Emergency Contact (name, phone, relationship):
Referred to us by:
Family Physician (name, clinic):
Other practitioners (chiropractor, osteopath, physical therapy, etc):
Main health concerns today (please list each concern and when the issue started):
Your past medical history
Indicate any past symptoms/condition and the dates you experienced these symptoms/conditions:
___Acne
___Hemorrhoids
___AIDS
___Hepatitis
___Alcohol/drug problems
___Herpes
___Allergies
___Hiatal hernia
___Animal Bites
___High blood pressure
___Antibiotics>1x/yr
___High cholesterol
___Amalgams/silver fillings
___Hives
___Anemia
___Hypoglycemia
___Anorexia
___Insomnia
___Anxiety
___Kidney infection
___Arteriosclerosis
___Kidney stones
___Arthritis
___Liver disease
___Asthma
___Lyme’s disease
___Back pain/strain
___Menstrual/pre-menstrual problems
___Bad breath
___Mental illness
___Binge eating/bulimia
___Migraines
___Bladder infections
___Nervous condition
___Bleeding problems
___Neurologic condition
___Blood clots
___Overweight (20#)
___Breast lumps
___Panic attacks
___Bronchitis
___Pelvic infection
___Bruising, easily
___Peptic ulcer
___Cancer
___Periodontal disease
___Cataracts
___Pneumonia
___Chemical Sensitivity
___Prostate problems
___Chicken Pox
___Rheumatic fever
___Chronic fatigue
___Scarlet fever
___Colds, frequent
___Shingles
___Colitis
___Sinusitis
___Congenital condition
___Skin problems
___Depression
___Sleep disorder
___Diabetes
___Stroke
___Ear infection, chronic
___Syphilis
___Eczema
___Taken steroids(cortisone/prednisone)
___Endometriosis
___Thyroid problem
___Epilepsy/seizures
___Tonsillitis
___Epstein Barr/Mononucleosis
___Tuberculosis
___Fibrocystic breasts
___Bedwetting
___Fibroids
___Urinary tract infection
___Gallbladder problems
___Vaccination reaction
___Glaucoma
___Vaginitis
___Gonorrhea
___Vision problem
___Gout
___Warts
___Hay fever
___Whooping cough
___Hearing Problems
___Other
___Heart attack
___Other
___Heart problems
___Other
Surgeries (list all surgeries and dates):
Other hospitalizations and dates:
Broken bones, traumatic injuries, concussions, accidents, along with dates:
Check items that apply to blood relatives and list the person(s) indicated (children, parents, siblings, grandparents, aunts, uncles)
___Check if family history is unknown
___ High cholesterol/fat
___Alcohol/drug problems
___ Hormonal imbalance
___Allergy/Asthma
___Hypertension
___Anemia
___Kidney disease
___Arteriosclerosis
___Liver disease
___Arthritis
___Mental illness
___Bleeding problem
___Obesity
___Cancer
___ Sexually transmitted disease
___Diabetes
___ Skin disease
___Eating disorder
___Stroke
___Epilepsy/seizure
___Suicide
___ Gastro-intestinal disease
___Thyroid disease
___ Heart disease
___Tuberculosis
___ High blood pressure
___Other
Your Family
Family Age If deceased, cause of death
Children Age Conditions or N/A
Father
Mother
Siblings
Review of Systems
Please check if you have experienced these symptoms in the last six months.
___Chronic fatigue
___Dry mouth
___Mucus in stool
___Mood swings
___Dental problems
___Blood in stool
___Chronic depression
___Excessive salivation
___Rectal bleeding
___Trembling episodes
___Bleeding gums
___Abdominal pain
___Light-headedness
___Canker sores
___Hemorrhoids
___Food cravings
___Coating on tongue
___Frequent urination
___Frequent infections
___Chronic cough
___Bedwetting
___Night sweats
___Bloody/yellow sputum
___Blood in urine
___Excessive sweating
___Shortness of breath, exertion
___Pain/burning w/urination
___Swollen glands
___Shortness of breath, night
___Foul odor to urine
___Skin rash
___Chest pain with breathing
___Low back pain
___Headaches
___Chest pain/pressure w/ stress
___Loss of urine control
___Seizure/convulsions
___Chest pain/pressure w/ eating
___Other
___Poor memory
___Chest pain/pressure w/sweating
___Other
___Difficulty concentrating
___Chest pain/pressure w/nausea
___Other
___Fainting
___Chest pain/pressure w/anxiety
___Weakness
___Chest pain/pressure at rest
MEN:
___Insomnia
___Irregular heartbeat
___Decreased urine stream
___Chills/fever
___Heart skips beats
___Dribbling after urination
___Restlessness
___Heart palpitations
___Enlarged prostate
___Irritability
___Fast heart beat
___Pus/drainage from penis
___Dizziness
___Heart murmur
___Genital swelling
___Balance problems
___Swollen hands/feet
___Genital rash
___Numbness/tingling
___Cold hands/feet
___Problem w/sexual function
___Change in skin/nails
___Leg cramps at night
___Abnormal PSA
___Change in mole/wart
___Joint pain
___Low sperm count/infertility
___Abnormal bleeding/bruising
___Pain/fatigue in legs w/exercise
___Change in hair loss/growth
___Burning feet
WOMEN:
___Blurred vision
___Color change legs/feet
___Spotting between periods
___Double vision
___Color change nails
___Discomfort with periods
___Halos around lights
___Frequent belching
___Change in cycle
___Tearing/itching of eyes
___Pain relieved by eating
___Vaginal discharge
___Eye pain
___Difficulty swallowing
___Painful intercourse
___Loss of vision
___Pain/discomfort w/eating
___Infertility
___Loss of hearing
___Nausea/vomiting
___Problem w/sexual function
___Ringing/buzzing in ears
___Trouble with fried foods
___Vaginal itching
___Sinus trouble
___Bloating of abdomen
___Vaginal pain
___Nosebleeds
___Bowel gas
___Lump in breast
___Bad breath
___Diarrhea
___Abnormal pap smear
___Sore throat/strep
___Constipation
___Premenstrual tension
___Hoarseness
___Black stool
___Change in voice
___Clay colored stool
Women
Date of last menstrual period:
Age at start of menstruation:
Number of pregnancies:
Number of live births:
Number of abortions/miscarriages:
Pregnancy complications?
Used birth control pills?
Usual length of cycle:
Usual length of period:
Is flow heavy or light?
Age at menopause:
Date of last pap smear:
Current medication (list all prescriptions and non-prescriptions including dosage):
Supplements (type and dosage):
Allergies to medications:
Food allergies (include method of testing):
List your favorite foods or cravings:
List any foods you especially dislike:
Generally, how is your appetite?
Generally, how is your thirst?
Are you now or have you ever been a smoker/tobacco user?
If so, how many years have you smoked/used tobacco?
How much?
When did you quit?
I estimate my use of coffee to be _______ cups per day.
I estimate my use of tea/other caffeinated beverage to be ______ cups per day.
Do you consider yourself a ___non-drinker ___social drinker ___heavy drinker ___ alcoholic
___ recovering alcoholic
Do you use marijuana?
Other drugs?
Do you exercise regularly?
What is your favorite type of exercise?
Do you find your work rewarding?
What are your favorite activities for relaxation/recreation?
What is your favorite type of weather? Time of year?
Do you worry about money? ____ job? ____ family? ______ relationships? ______ other? ___________
Do you sleep well?
How many hours do you sleep per night?
Do you use sleep aids?
Do you have any fears?
In the past 12 months, have there been any significant changes in your life?
Personal life:
Family life:
Social life:
Work life:
Sex life:
Spiritual life:
Any other significant changes?