The following information is used to help determine how to best treat your health issues. Please complete to the best of your abilities.
Please list the concerns you have about your health today.
Please check conditions you currently have or have had in the past:
If you checked other please list them here:
Check if your blood relations have had any of the following:
Please indicate symptoms you currently have (C) or have had in the past (P). Please note quality of symptoms.
RashesHivesDry skinAcneEasily bruisedChanges in lumps or molesUnusual bleedingOther
Head and Neck
Headaches (note type andlocation of pain)DizzinessJaw painOther
Eyes and Ears
Failing visionBlurred visionVisual spotsNight blindnessEye pain/swellingRinging in the earsDecreased hearingEar painEar dischargeOther
Nose, Throat, Mouth
Nose bleedsNasal discharge/infectionFrequent sneezingChange in sense of smellSore throatHoarsenessDifficulty in swallowingChange in sense of tasteTooth or gum painBleeding gumsMouth or tongue ulcersOther
Muscles and Joints
Pain, weakness or numbness in:
Neck/Shoulder/Arm/HandHips/Leg/FeetSore low back and kneesMuscle crampsBody painHeavy limbsSwollen jointsHot joints
Heart, Lungs and Chest
PalpitationsChest painTightnessRapid heart beatIrregular heart beatSwelling of the anklesCoughDry CoughCoughing up phlegmCoughing up bloodShortness of breathAsthma/wheezingFrequent coldsPain in rib cageOther
Difficulty concentratingPoor memoryWorryAnxietyDepressionIrritabilityFrustration or angerFearfulnessStressOther
NauseaVomiting foodVomiting bloodDiarrheaConstipationLoose stoolsBloody/black stoolsStomach painAbdominal painPoor appetiteExcessive hungerAbdominal bloating/gasBelchingIndigestionAcid refluxHemorrhoids
Painful urinationDifficult urinationFrequent daytime urinationFrequent nighttimeurinationIncontinenceCloudy urineBloody urineGenital pain or itchGenital discharge orlesionsPainful intercourseLow sexual driveExcessive sexual driveOther
ImpotenceWeak urinary streamProstate hypertrophyPremature ejaculationSeminal emissions
Irregular periodsPainful periodsBleeding between periodsPassing clotsScanty periodsEarly periodsNo periodsPMSMenopausal symptomsAbnormal PAP smearBreast lumpBreast pain or dischargeVaginal dischargeOther
Please note if you have ever been hospitalized and why:
List any medications or supplements you are currently taking along with the dosage.
List any medication, food or environmental substances that you are allergic to and the reaction you have.
How much of each substance do you consume and how often?
Describe your diet in general terms. Please include in your description how many meals you eat
daily, how often you eat out, if you have any dietary restrictions and what your favourite foods are.
If yes, describe the type of activity you do and how often you do it.
Please answer the following questions if applicable to you.
Describe your typical period including any PMS symptoms you experience:
Quality of Blood:
Light redBright redDark RedClottedOther
If you checked other please describe:
If you are in menopause please describe the age of onset and the past and current symptoms you
Are you currently pregnant?
Are you trying to become pregnant?
If you use birth control pleased note what method you use and how long you have been using this method:
Please note the number of pregnancies you have had, the number of deliveries you have had and any related information i.e. heavy bleeding with delivery, problem free delivery etc.