Health Assessment

All collected information is confidential and will not be shared with any outside parties

Basics

What is your current address?

When is your birthday?

Where were you born?

What is your gender?

What is your marital status?

What do you do for a living?

What is your level of education?

Wellness Goals

What are your wellness goals?

When was the last time you felt well?

How motivated are you to make changes to your health

Did something trigger your change in health?

Personal Medical History

All medical information is confidential and will not be shared with any outside parties

Current medications

Current supplements

Do you currently or have you previously experienced any of the following? - select all that apply

Irritable Bowel Syndrome pastongoingN/A

Crohn's Disease pastongoingN/A

Ulcerative Colitis pastongoingN/A

Peptic Ulcer Disease pastongoingN/A

GERD (reflux) pastongoingN/A

Celiac Disease pastongoingN/A

--- --- --- --- ---

Heart Attack pastongoingN/A

Heart Disease pastongoingN/A

Stroke pastongoingN/A

Elevated Cholesterol pastongoingN/A

Arrhythmia (irregular heart rate) pastongoingN/A

Hypertension pastongoingN/A

Rheumatic FeverpastongoingN/A

Mitral Valve ProlapsepastongoingN/A

Other Heart Condition pastongoingN/A

--- --- --- --- ---

Type 1 Diabetes pastongoingN/A

Type 2 Diabetes pastongoingN/A

Hypoglycemia pastongoingN/A

Metabolic Syndrome pastongoingN/A

Hypothyroidism (low thyroid) pastongoingN/A

Hyperthyroidism (overactive thyroid) pastongoingN/A

--- --- --- --- ---

Polycistic Ovarian Syndrome pastongoingN/A

Infertility pastongoingN/A

Weight GainpastongoingN/A

Weight LosspastongoingN/A

Eating Disorder pastongoingN/A

--- --- --- --- ---

Kidney Stones pastongoingN/A

Gout pastongoingN/A

Interstitial Cystitis pastongoingN/A

Frequent Urinary Tract Infections pastongoingN/A

Frequent Yeast Infections pastongoingN/A

Erectile Dysfunction pastongoingN/A

Sexual Dysfunction pastongoingN/A

Herpes - Genital pastongoingN/A

--- --- --- --- ---

Osteoarthritis pastongoingN/A

Fibromyalgia pastongoingN/A

Chronic Pain pastongoingN/A

Chronic Fatigue Syndrome pastongoingN/A

Autoimmune Disease pastongoingN/A

Rheumatoid Arthritis pastongoingN/A

Lupus SLEpastongoingN/A

Immune Deficiency Disease pastongoingN/A

Severe Infectious Disease pastongoingN/A

Poor Immune Function pastongoingN/A

Food allergies pastongoingN/A

environmental Allergies pastongoingN/A

Multiple Chemical Sensitivities pastongoingN/A

Latex Allergy pastongoingN/A

--- --- --- --- ---

Asthma pastongoingN/A

Chronic sinustis pastongoingN/A

Bronchitis pastongoingN/A

Emphysema pastongoingN/A

Pneumonia pastongoingN/A

Tuberculosis pastongoingN/A

Sleep apneapastongoingN/A

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Eczema pastongoingN/A

Psoriasis pastongoingN/A

Acne pastongoingN/A

Melanoma pastongoingN/A

SKin cancerpastongoingN/A

Other cancer pastongoingN/A

--- --- --- --- ---

Lung cancer pastongoingN/A

Breast cancerpastongoingN/A

Colon cancerpastongoingN/A

Ovarian cancerpastongoingN/A

Prostate cancer pastongoingN/A

Skin cancer pastongoingN/A

--- --- --- --- ---

Depression pastongoingN/A

Anxiety pastongoingN/A

Pipolar DisorderpastongoingN/A

Schizophrenia pastongoingN/A

Headaches pastongoingN/A

Migraines pastongoingN/A

ADD/ADHD pastongoingN/A

Autism pastongoingN/A

Memory Problems pastongoingN/A

Dementia/Alzheimer's pastongoingN/A

Parkinson's Disease pastongoingN/A

Multiple Sclerosis pastongoingN/A

Seizures pastongoingN/A

Other Mental Health pastongoingN/A

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Over The Counter Medication History - select all that apply

NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.) currentlypast regular userarely usednever

Tylenol (Acetaminophen) currentlypast regular userarely usednever

Acid blockers (Tagamet, Zantac, Prilosec, etc.) currentlypast regular userarely usednever

Antibiotics currentlypast regular userarely usednever

Steroids currentlypast regular userarely usednever

Oral contraceptives currentlypast regular userarely usednever

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What is your genetic background?

Do you have any known drug allergies?

What is your blood type?

On average how many hours of sleep do you get each night?

Please list any significant physical trauma you've experienced:

Please list any significant emotional trauma you've experienced:

Gynecological History

All medical information is confidential and will not be shared with any outside parties

Gynecological history - select all that apply
fibrocystic breastsfibroidspainful periodsPMDDendrometriosisinfertilityheavy periodsnonenot applicable

Current use birth control - select all that apply
pillshormonal patchesnuva ringcondomsdiaphragmhormonal IUDnon-hormonal IUDpartner vasectomynonenot applicable

Previous use birth control - select all that apply
pillshormonal patchesnuva ringcondomsdiaphragmhormonal IUDnon-hormonal IUDpartner vasectomynonenot applicable

Patient birth history - select all that apply
vaginal deliveryc-sectionfull termprematuregestational diabetesbaby over 8 poundstoxemianonenot applicable

Patient breast feeding history - select all that apply
breast-fedbottle fednone/not applicable

Menopausal patients history - select all that apply
hot flashesconcentration/memory problemsdecrease libidoweight gainpalpitationsmood swingsvaginal drynessheadachesloss of control of urinedifficulty sleepingnonenot applicable

Men's History

All medical information is confidential and will not be shared with any outside parties

Men's health history - select all that apply
prostate enlargementprostate infectionchange in libidoimpotencedifficulty obtaining an erectiondifficulty maintaining an erectionfrequent urination at nighturgency/hesitancy/change in streamloss of urine control

Dental History

All medical information is confidential and will not be shared with any outside parties

silver mercury fillingroot canalstooth paingingivitisgold fillingsimplantsbleeding gumsfloss regularly

Family History

All medical information is confidential and will not be shared with any outside parties

Cancers motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Colon motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Breast/Ovarian cancers motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Heart Disease motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Hypertension motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Obesity motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Diabetes motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Stroke motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Inflammatory Arthritismotherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Inflammatory Bowel Disease motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Multiple Sclerosis motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Autoimmune Diseasemotherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Irritable Bowel Syndrome motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Celiac Diseasemotherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Asthma motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Eczema/Psoriasis motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Food Allergies/Sensitivities motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Environmental Sensitivities motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Dementia motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Parkinson's motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

ALS or other motor neuron diseasemotherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Genetic Disorders motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Substance Abuse motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Psychiatric Disorders motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Depression motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Schizophrenia motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

ADD/ADHD motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Autism motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

Bipolar disease motherfathersiblingchildmaternal grandparentpaternal grandparentnot applicable

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