Health History Initial Form **Please note all of your personal information will remain strictly confidential** Name* First Last Email* Social Media LinksAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* Date Format: DD slash MM slash YYYY Place of Birth*Age*Gender*Height*Weight*Would you like your weight to be different?*YesNoIf so, what? Occupation*How many hours do you work per week?*Relationship Status*Number of Children*Blood Type (If Known)Referred ByHobbies/Activities* What would you like to accomplish/gain from this consultation?*Do you sleep well?*YesNoDo you wake up during the night?*YesNoIf so, what time?What time do you go to bed and wake up?*How do you feel when you wake up?*Do you drink caffeinated drinks?*YesNoIf so, how much and how often?Do you smoke?*YesNoIf so, how much and how often?If no, have you ever, or when and why did you quit?Any exposure to second hand smoke?*YesNoIf so how much and how long?Do you drink alcohol?*YesNoHow much and how often?Do you drink fizzy drinks?*YesNoHow much and how often?What role does exercise play in your life?*Have you been exposed to toxic substances at work or home?*YesNoHow much water do you drink per day?*Are you currently taking any supplements, prescriptive or non-prescriptive medications, laxatives, diet pills or anything else?*Do you have any known allergies to medications or herbs?*YesNoAre you currently under a practitioner's care for a specific health issue?*YesNoIf so, what treatment are you undergoing?Please list any surgeries, accidents, injuries or childhood diseases you had along with the type and date: What were your eating habits like as a child? (List types of food)What percentage of your food is home cooked?*How often do you eat out?*What are the 3 worst foods you eat each week?*What are the 3 healthiest foods you eat each week?*Do you crave sugar?*YesNoDo you crave salt?*YesNoDo you feel tired, bloated and/or gassy after meals?*YesNoDo you experience constipation or diarrhea often?*YesNoWhen and how often?Do you feel excessively hungry?*YesNoDo you have poor appetite?*YesNo Family Health History Does anyone in your family have a history of any of the following?Diabetes?*YesNoHeart Disease?*YesNoCancer?*YesNoIf yes, what type of cancer?Kidney Disease?*YesNoArthritis?*YesNoAsthma?*YesNoGallbladder Disease?*YesNoStomach/Intestinal Disorders?*YesNoMother's AgeMother's Cause of DeathFather's AgeFather's Cause of DeathMaternal Grandmother's AgeMaternal Grandmother's Cause of DeathPaternal Grandmother's AgePaternal Grandmother's Cause of DeathMaternal Grandfather's AgeMaternal Grandfather's Cause of DeathPaternal Grandfather's AgePaternal Grandfather's Cause of Death Women OnlyAge of your first periodAre your periods regular?YesNoHow frequent?Number of PregnanciesHow many days is your flow?Do you experience PMS?YesNoIf yes is it mild or severe?Are you peri-menopausal?YesNoIf yes, when did this change first occur?Are you menopausal?YesNoWhen was your last period?List your symptoms of peri/menoipause:How many children have you delivered and how were thy born (Vaginally or by cesarean)?Were there any complications associated with these births?YesNoPlease explain:Did you receive antibiotics during the labour?YesNoHave you ever had a miscarriage or an abortion?YesNoIf so, how many? Men OnlyApproximate age of onset of pubertyNumber of ChildrenDo you feel your libido is adequate?YesNoCommentsDo you wake at night to urinate?YesNoHow many times per night?Do you have any difficulty or pain associated with urination?YesNoDiminished volume or flow?YesNoDo you enjoy daily activities?YesNoDo you feel apathetic or complacent about previously enjoyed sports, hobbies, clubs, games, etc?YesNoDo you notice feeling more agitated/irritable than you did previously?YesNoDo you feel less assertive in daily life than previously?YesNo EveryoneDo you have any other questions, comments or concerns? Δ
