HEALTH HISTORY (Confidential)
	GENERAL INFORMATION: Name: Age: Male Female Telephone: E-mail address: Zip code: _____________________________________________________________________ Major Complaint(s), in order of significance to you: Severe  Moderate  Slight 1. 2. 3. 4. 5. SYMPTOMS I   Check off symptoms you currently have or have had in the past year: Fatigue after meals General weakness Low energy Sleepy in daytime Tired after exercise Anxiety Anger easily Depression Fear Hot temper Melancholy Mental confusion Mental sluggishness Nervousness Over thinking Pensive Restlessness Sadness Worry Easily catching cold Abrupt weight gain Abrupt weight loss Cravings Taking water to bed Thirst Large appetite Low appetite _____________ Difficulty falling asleep Disturbed sleep Dizziness Frequent dreams Forgetfulness Lightheadedness Sleepiness Waking up not refreshed _____________ Afternoon flashes Cold feet Cold hands Heat in the hands/feet/chest Hot flashes Night sweats Lack of perspiration Perspire easily _____________ Dry skin Easily bruised Excessive hair loss Numbness Rashes/itchy Tingling SYMPTOMS II   Check off symptoms you currently have or have had in the past year: Headaches Migraines Bleeding gums Bitter taste in the mouth Dry mouth Sores on the tongue Sour taste in the mouth Tooth cavities Dry throat Lump in the throat Snoring Sore throat Cough: Persistent Dry With mucus: _____________ Eyes: Dry Itchy Red Yellowish Watery Pain in the eyes _____________ Clear Yellow Profuse Difficult to expectorate Chest congestion Chest pain Chest pain spreading to left shoulder Chest pain spreading to right shoulder Chest tightness _____________ Dry nose Nose bleeding Vision: Flashes Halos Blurred Floaters Nasal discharge: _____________ Clear Yellow Sinus congestion Sneezing Ringing in the ears SYMPTOMS III   Check off symptoms you currently have or have had in the past year: Hemorrhoids Blood in stools Mucous stools Undigested food in stools Blood in urine Scanty urine Profuse urine Strong odor Bad breath Nausea Belching Acid regurgitation Heart burn Stomach pain Vomiting Abdominal bloating/gas Frequent urination Night urination Lack of bladder control Painful/burning urination Color of urine: Stools: Dark yellow Light yellow Colorless Cloudy Loose Constipated Alternating Incomplete Diarrhea SYMPTOMS IV   Check off symptoms you currently have or have had in the past year: Other: Premature ejaculation Erectile difficulties Breast lumps Nipple discharge Lump in testicles Sore on penis High libido Low libido _____________ Infertility Low sperm count Low sperm motility _____________ After intercourse: General weakness Weak/achy lower back Weak/shaky knees Headache Penis discharges: _____________ Clear Yellow Milky Greenish Bloody Prostate problems SYMPTOMS V  Check off symptoms you currently have or have had in the past year:   Pain Aches Stiffness Numbness Tingling Neck/shoulder Arm Hand Fingers/toes Upper back Lower back Hip Leg Knee Feet All body Cold knees/back Easily broken bones Heaviness in the body Muscle cramping Swollen feet Swollen joints Weak knees CONDITIONS  Check off conditions you have or have had in the past: AIDS Alcoholism Allergy Anemia Anorexia Appendicitis Arthritis Asthma Bleeding disorders Bronchitis Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Goiter Gout Heart Disease Hepatitis Hernia Herpes High Cholesterol High Blood Pressure HIV Positive Kidney Disease Liver Disease Low Blood Pressure Measles Migraine/headaches Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Prolapsed Organs Psychiatric Care Rheumatic Fever Scarlet Fever Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Typhoid Fever Ulcers Venereal Disease MEDICATIONS                                                                                  ALLERGIES List medications you are currently taking Please, list allergies HEALTH HABITS                                                                               OCCUPATIONAL CONCERNS Check off which substances you use and describe how much you use   Check off if your work exposes you to the following Caffeine Tobacco Drugs Other Stress Hazardous substances Heavy lifting Other: SERIOUS ILLNESS/INJURIES                                                           HOSPITALIZATIONS List serious illnesses/injuries, indicate date and outcome List hospitalizations, indicating year and reason FAMILY HISTORY  Fill in health information about your family: Check off if your blood relatives had any of the following: Relationship Alive Deceased Present health or cause of death Father Mother Brother Brother Brother Sister Sister Sister Allergies Bleeding tendency Diabetes Cancer Heart disease/ stroke Kidney disease Mental/nervous illness Obesity Tuberculosis Other: First  Last  Middle Only Where are you in the birth order? ______________________________________________________________________