Adult Health History Form Kristin Stiles Green, NMD NEW FORM
Adult Health History FormKristin Stiles Green, NMD, FABNO
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PROACTIVE HEALTH CARE IS ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE UNDERSTANDING OF THE PERSON MENTALLY, PHYSICALLY, AND EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE.
PLEASE, PRINT! MARK ANYTHING YOU DON’T UNDERSTAND WITH A QUESTION MARK.
Are you hypersensitive or allergic to:
Do you use smoke, vape, or use cannabis?
Are you currently receiving healthcare for any reason?
PLEASE LIST ALL VITAMINS, HERBS, SUPPLEMENTS, PRESCRIPTION MEDICATIONS, AND OVER THE COUNTER MEDICATIONS YOU ARE TAKING ON A REGULAR BASIS. Please include ingredients, milligram amounts, how often taken, etc.PLEASE BRING IN THE BOTTLES OR LABELS or EMAIL US clear photos of the front and back labels of EACH bottle so I can see the details.
What surgeries have you had for your condition and when?
Have you had or are you now receiving any chemotherapy (oral or IV) or immunotherapy treatment? If yes, which drugs, how many cycles, when was your last treatment, etc.?
Have you had any radiation treatments of any type? Which body part(s)? Approximately how many treatments and when?
FAMILY HISTORY
Please note if any of these diseases/problems are (or were) applicable to your parents, grandparents, uncles, aunts, or siblings. Please note for whom it was a problem.
If not, please note their cause of death and at what age(s), if known?
Typical Food Intake- Examples, as we know it varies…
For the following sections, please use this KEY:
Y = a condition you have now N = a condition you have never had P = had in the past
BLOOD/PERIPHERAL VASCULAR
BONES/BACK/NECK/JOINTS/MUSCLES
FEMALE REPRODUCTIVE SYSTEM
MENTAL / EMOTIONAL / PSYCHOLOGICAL
Please choose your difficulty for paying for basic expenses like food, housing, medical care, and utilities.
How do your current health conditions affect you?
What do you feel needs to happen for you to feel better?
What do you enjoy most in your life?
How much change are you willing to make, currently, to improve your health?
Is there anything else you would like to add?
Welcome! We are glad to serve you!
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