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Name(*)
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Address
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Email Address(*)
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Phone Number
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Date of Birth
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What is the Chief Complaint (main problem) you are coming in for today?
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When did this problem begin? What happened in your life around that time? What do you think caused it?
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What aggravates the problem (certain types of food or weather, movement, light, noise, heat/cold, or anything else you can think of)?
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At what time of the day or night is the problem the worst? Specify an hour if you can.
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What symptoms can you identify that accompany the problem?
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Please provide brief health history.
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Frequency of bowel movements (BM): If you don’t have a BM, do you use laxative?
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How frequently do you get colds and flu?
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Have you had any childhood illnesses twice, or in a very severe form or after puberty?
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Have you had vaccinations since the standard childhood ones? Have you ever had an adverse reaction or unusual reaction to vaccinations?
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Have you had any surgery? What type and when?
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What other medical problems/diagnoses have you been treated for.
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List or give sheet of present medications you are taking—tell us to the best of your knowledge the reason you were prescribed this medication. How long have you been taking each medication?
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List any supplements (vitamins) and herbs you are taking or give a sheet with them and tell us to the best of your knowledge why you are taking them and how long you have been taking them.
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Are you presently on any Homeopathic remedies? If so, which one and what is the potency, dose and how often do you take it? Have you had any adverse reactions or aggravations to any remedies?
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DIET: Food Likes/dislikes?
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Please list any other concerns or questions you would like to discuss.
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Verification(*)
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