Confidential Medical History Form

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:

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

Prostate Problems

Testicular Cancer

Vasectomy

Sexual Dysfunction

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

Confidential Medical History Form

Give Your Personal Detail

Name

Email

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