Health Survey

Confidential Patient Health Profile

The following information is used to help determine how to best treat your health issues.  Please complete to the best of your abilities.

Personal Information

Phone Numbers:

Physician Information:

Emergency Contact:

Referral Information:

Sex: MaleFemale

Health Concerns:

Please list the concerns you have about your health today.


Please check conditions you currently have or have had in the past:

AIDSAlcoholismAllergiesAnemiaAnorexiaArthritisAsthmaBleeding DisorderBronchitisBulimiaCancerCataractsChemical DependencyChicken PoxChronic PainDiabetesEczemaEmphysemaEpilepsy

Fatigue ProblemGallbladder ProblemGerman MeaslesGlaucomaGoiterGoutHeart DiseaseHepatitisHerniaHerpesHigh Blood PressureHigh CholesterolIntestinal DisorderKidney DiseaseLiver DiseaseLupusMeaslesMenstrual DisorderMigraines

MiscarriageMononucleosisMultiple SclerosisMumpsPacemakerPneumoniaPolioProstate ProblemPsychiatric CareRheumatic FeverStrokeStomach DisorderThyroid DisorderTuberculosisUlcersUrinary Tract InfectionVaginal InfectionVenereal DiseaseOther

If you checked other please list them here:

Family History:

Check if your blood relations have had any of the following:

Arthritis/GoutAsthmaCancerChemical Dependency

DiabetesHeart DiseaseHigh Blood PressureKidney Disease


If you checked other please list them here:


Please indicate symptoms you currently have (C) or have had in the past (P). Please note quality of symptoms.

FatigueInsomniaDisturbed sleepFrequent dreamsExcessive sleepDislike coldDislike heatWeight lossWeight gainFeverChillsAlternating chills and feverNight sweatsUnusual daytime sweatingUsually thirstySeldom thirstyEdema or swellingOther

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

Nervous System
FaintingParalysisTremorsPoor balanceSeizuresOther

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

Digestive System
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

If you checked other please list them here:


Please note if you have ever been hospitalized and why:

Medications and Supplements:

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.

Health Habits:

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.

Women Only:

Please answer the following questions if applicable to you.

Menstrual Cycle:
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

Pregnancy and Birthing History:

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.