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Confidential Medical History Form
These forms include a number of questions addressing diet, lifestyle, past medical history, and family medical history. Please take time to fill this Medical History form. All the answers are important in the evaluation of your health conditions.
What medications are you taking now? (Include prescription and over-the-counter drugs.)
List family members who have or had this illness
- PERSONAL DETAIL
- MEDICATIONS
- FAMILY MEDICAL HISTORY
- REPRODUCTIVE HISTORY
- DIET
Give Your Personal Detail
Name
Date Of Birth - DD-MM-YYYY
Home Phone
Mobile Phone
Occupation
What health problems would you like us to address?
PERSONAL MEDICAL HISTORY
Energy
Gynecological
Muscles / Bones / Joints
Nervous system
Allergies / Immune System
Hormonal / Endocrine
Digestion / Elimination
Psychiatric / Psychological
Blood
Ears / Nose / Throat / Sinuses
Eyes
Lungs
Bladder / Kidneys / Urination
Skin
Heart / Circulation
Please list any operations/surgical procedures/blood transfusions/major injuries (with dates):
Immunizations/vaccinations
MEDICATIONS
Medication 1
Reason
When Started - DD-MM-YYYY
Dosage per day
MEDICATIONS
Medication 2
Reason
When Started - DD-MM-YYYY
Dosage per day
MEDICATIONS
Medication 3
Reason
When Started - DD-MM-YYYY
Dosage per day
MEDICATIONS
Medication 4
Reason
When Started - DD-MM-YYYY
Dosage per day
MEDICATIONS
Medication 5
Reason
When Started - DD-MM-YYYY
Dosage per day
MEDICATIONS
Are you allergic to or have you had a “bad reaction” to any medications or other substances?
If yes, please specify drug(s) and type of reaction:
FAMILY MEDICAL HISTORY
Arthritis
Alcoholism
Cancer: Breast
Cancer: Colon
Cancer: Prostate
Cancer: Other
Depression or Bipolar Disorder
Diabetes
Heart disease
High blood pressure
Other:
Other:
WOMEN ONLY:- Reproductive History
Age at 1st menstrual period
First day of most recent menstrual period
Usual Flow
Heavy
Moderate
Light. Length of period in days
Number of days between periods
Do you have (please circle): Painful Periods, Missed Periods, Spotting Between Periods, Vaginal Bleeding, Unusual Discharge/Infection, Recurring Vaginal Infections If you have gone through menopause, have you had any post-menopausal bleeding?
Date of last Pap - DD-MM-YYYY
History of abnormal Paps?
Number of: Pregnancies
Live Births
Abortions
Miscarriages
Have you experienced complications during pregnancy/delivery/other problems?
Contraceptive History
Birth Control Pills. Type
Total Years of Use
Diaphragm/Cap. Type
Size
IUD. Type
Date of Last Change - DD-MM-YYYY
Norplant, Condom and/or Foam, Suppository
Tubal Ligation
Hysterectomy
Partner with Vasectomy
Other
Problems with current method
MEN ONLY
Do you have
SUPPLEMENTS:- List all vitamins, minerals, herbs and other nutritional supplements
Supplement
When Started - DD-MM-YYYY
Daily Dosage
SUPPLEMENTS
Supplement
When Started - DD-MM-YYYY
Daily Dosage
SUPPLEMENTS
SUPPLEMENT
When Started - DD-MM-YYYY
DAILY DOSAGE
DIET
List any food sensitivities or intolerances
Are you on any special diet? What foods do you avoid? Why?
List your typical diet (include beverages) over 7days :- Monday
Breakfast
Lunch
Dinner
Snacks
Tuesday
Breakfast
Lunch
Dinner
Snacks
Wednesday
Breakfast
Lunch
Dinner
Snacks
Thursday
Breakfast
Lunch
Dinner
Snacks
Friday
Breakfast
Lunch
Dinner
Snacks
Saturday
Breakfast
Lunch
Dinner
Snacks
Sunday
Breakfast
Lunch
Dinner
Snacks
SUBSTANCE USE
Cigarettes :- Smoked from age (packs per day)
To
Other Tobacco :- Cigars, Pipes Snuff, Chewing Tobacco Used from age (times per day)
To
Alcohol :- (Estimate drinks per week) Alcohol problem from age
To
Use of other recreational drugs?
WELLNESS
What exercise do you do?
How often do you exercise?
What mind-body practice do you have (e.g. meditation, yoga, prayer)? How often do you do this?
What complementary and alternative medicine therapies do you use? E.g. acupuncture, massage, homeopathy etc
List you leisure activities/hobbies
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