Adult Health History Form
Kristin Stiles Green, NMD

SUCCESSFUL HEALTH CARE IS ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE UNDERSTANDING OF THE PERSON PHYSICALLY, MENTALLY AND EMOTIONALLY.
PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE.
PLEASE, FILL AND MARK ANYTHING YOU DON'T UNDERSTAND WITH A QUESTION MARK.

Name

Date

Age

Date of Birth

Gender Identity

Address

City

State

Zip Code

Phone #’s

Email Address

Person(s) to reach in an emergency

Relationship(s)

Phone #’s

Is any other family member already seeing me?

May I thank someone for referring you to me?

Are you hypersensitive or allergic to:

Any drugs?

Any foods?

Any environmental things?

Do you use tobacco, currently?

Yes

No

Smoked previously?

Yes

No

How many years?

How many packs per day?

Are you currently receiving healthcare for any reason?

Yes

No

If yes, from whom?

For what reason(s)?

Do you have a primary care doctor or other health care providers you see regularly, for any reason? Please list:

Do you have a diagnosed illness or disease that we should list as a part of your health history?

What are your top FIVE most important health problems or goals, in order of importance.

What are your top FIVE most important health problems or goals, in order of importance.

What are your top FIVE most important health problems or goals, in order of importance.

What are your top FIVE most important health problems or goals, in order of importance.

What are your top FIVE most important health problems or goals, in order of importance.

Current Medications/Supplements/Herbs/Homeopathics:
Please list ALL vitamins, herbs, supplements AND prescription medications OR over the counter medications you are taking, regularly.
Please include ingredients, milligram amounts, how often taken, etc.
For multi-ingredient products, PLEASE BRING IN THE BOTTLES OR CLEAR PHOTOS OF THE FRONT AND BACK LABELS, so I may see the detail.

Height

Weight today

Weight one year ago?

Maximum weight

When?

Desired weight

CANCER PATIENTS, ONLY

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?

FOR ALL OTHER CONDITIONS

What surgeries have you had and when?

When have you been hospitalized and what for?

SOCIAL HISTORY

Are you:

Are you: ( choose from list)SingleMarriedDivorcedin a Significant PartnershipWidowed

DO YOU Live:

DO YOU Live: ( choose from list)Alonew/Spousew/Childrenw/Partnerw/Parent(s)w/ Roommates

Occupation

Hours per week

Retired?

Employer

In a typical week, how many times do you talk in person on the telephone with family, friends, or neighbors?

In a typical week, how often do you get together with friends, relatives, or neighbors?

Do you belong to any social organizations, groups, churches, spiritual groups or practices?

Main interests and hobbies:

SCREENINGS:

Date of last Physical Exam?

Colonoscopy?

Labs?

Males: Prostate Exam?

Females: Last PAP smear or pelvic exam?

Females: Last mammogram?

FAMILY HISTORY

Please note if any of these disease/problems are/were applicable to your parents, grandparents, uncles, aunts, siblings or children. Please note for whom it was a problem.

Cancer & Type

Diabetes

Heart Disease

High Blood Pressure

Strokes

Mental Illness

Are your parents, grandparents, siblings and children all still living?

If not, please note their cause of death and at what age(s), if known?

Typical Food Intake - Examples

Breakfast:

Lunch:

Dinner:

Snacks:

Beverages:

EXERCISE

Do you exercise?

Yes

No

If yes, what type?

How often do you exercise?

How many minutes per week?

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

Do you average 7-8 hours of sleep?

Y

N

Sleep well?

Y

N

Awaken rested?

Y

N

Have a supportive relationship?

Y

N

Have a history of any abuse?

Y

N

Any major traumas?

Y

N

Do you eat 3 or more meals / day?

Y

N

Do you eat out, often (4x/week+)?

Y

N

Do you go on diets, often?

Y

N

Do you drink any coffee?

Y

N

Do you drink black tea?

Y

N

Do you add salt to your food?

Y

N

Do you enjoy your work?

Y

N

P

Take vacations?

Y

N

P

Spend time outside?

Y

N

Do you watch television?

Y

N

For TV, how many hours/day?

Do you read, regularly?

Y

N

How many hours/day?

Use alcoholic beverages?

Y

N

P

How much, how often?

Treated for alcoholism/drug addiction?

Y

N

Do you drink cola or other sodas/soft drinks?

Y

N

How many hrs./day for “Screen time”?

Sexual orientation

Are you, currently, having sex with a partner?

Yes

No

Any sexual difficulties?

Birth control used?

Do you have children? Please list names, sex, and ages.

Do you travel often for work?

Yes

No

Any remote locations or 3rd world countries?

Are you exposed to any chemicals of occupational hazards as a part of your day or work?

Do you have any pets? If so, please list type

HEAD

Do you have chronic headaches, migraines, a head injury history, TMJ problems, etc.? PLEASE LIST

EYES

Do you have impaired vision, visual disturbances, eye pain, “dry eye syndrome”, excessive tearing glaucoma, cataracts, macular degeneration, etc.? PLEASE LIST

EARS

Do you have impaired heating, ringing in your ears (tinnitus), ear pain, etc.? PLEASE LIST

NOSE AND SINUSES

Do you suffer from frequent colds or sinus infections, nose bleeds, loss of smell, etc.? PLEASE LIST

MOUTH AND THROAT

Do you have any issues with frequent sore throat/mouth/lips/tongue; hoarseness, teeth grinding, gum problems, dental problems, etc.? PLEASE LIST

SEASONAL ALLERGIES

Do you have any chronic, seasonal allergy symptoms? What are your symptoms? PLEASE LIST

RESPIRATORY

Do you have any issues with a chronic cough, asthma, wheezing, shortness of breath? PLEASE LIST

Have you had pneumonia or bronchitis, recently?

Have you been told you have COPD?

Do you have a Tuberculosis history?

CARDIOVASCULAR

Do you have a history of high cholesterol, heart attacks, blood clots, high blood pressure, chest pain, valvular problems, arrythmias, palpitations, etc.? PLEASE LIST

BLOOD/PERIPHERAL VASCULAR

Do you have excessive bruising, easy bleeding, circulation problems, chronic anemia, etc.? PLEASE LIST

GASTROINTESTINAL

Do you have any trouble with swallowing, nausea, vomiting, heartburn/acid reflux/GERD; an ulcer history, excessive bloating, burping, flatulence; hemorrhoids, liver disease, etc.? PLEASE LIST

HOW OFTEN DO YOU HAVE A BOWEL MOVEMENT?

Are your stools well formed, hard, painful, loose, diarrhea or difficult to pass?

Do you have a lot of straining or pass any blood or mucus with bowel movements?

BONES/BACK/NECK/JOINTS/MUSCLES

Do you have problems with joint pain, stiffness, arthritis, muscle cramps, muscle spasms, back pain, neck pain, etc.? PLEASE LIST

Have you had a bone density scan?

If yes, when was the last one?

Do you have osteopenia or osteoporosis?

NEUROLOGY

Do you have a history of seizures, loss of consciousness, memory issues, muscle weakness, numbness or tingling; paralysis, vertigo/dizziness, neurological disorders? PLEASE LIST

SKIN

Do you have issues with rashes, hives, eczema, acne, recurrent boils, unusual skin lesions or moles; hair loss? PLEASE LIST

ENDOCRINE

Do you have hyper or hypothyroidism, diabetes Type I or II, pituitary problems, etc.? PLEASE LIST

IMMUNE

Do you have a history of frequent infections, negative reactions to vaccinations, slow wound healing, etc.?

URINARY/KIDNEY

Do you have pain with urination, inability to hold your urine, urinary frequency, frequent infections, a history of kidney stones; kidney disease, etc.? PLEASE LIST

MALE REPRODUCTIVE SYSTEM

Do you have a history of hernias, testicular problems, prostates problems, sexually transmitted diseases?

FEMALE REPRODUCTIVE SYSTEM

Age of first period?

Age/date of last period?

Day 1 of period to Day 1 of next period = Days

Are periods/cycles regular?

Yes

No

Duration of bleeding for period?

Painful periods?

Yes

No

Heavy or excessive flow?

Yes

No

PMS symptoms?

Yes

No

If yes, what are your symptoms?

Endometriosis history?

Yes

No

Ovarian cyst history?

Yes

No

Fibroid tumors

Yes

No

Number of pregnancies

Number of live births

Number of miscarriages

Abnormal PAP history?

Yes

No

Sexually transmitted infections?

Yes

No

P

Cervical dysplasia?

Yes

No

P

Please list

Gynecological surgeries/procedures?

Menopausal symptoms?

Yes

No

Please list

Do you perform breast self-exams?

Yes

No

Breast pain/tenderness/nipple discharge?

Yes

No

MENTAL / EMOTIONAL / PSYCHOLOGICAL

Do you have a diagnosed, mental health disorder?

Do you have mood swings, depression, anxiety, get easily stressed?

Have you ever considered or attempted suicide?

When?

FINANCES

Describe your difficulty paying for basics like food, housing, medical care, and utilities.

Very hard

Hard

Somewhat hard

Not very hard

VIOLENCE

Within the last year, have you been humiliated or abused by your partner or ex-partner?

Within the last year, have you been afraid of your partner or ex-partner?

Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?

Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?

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?

MINIMAL? SOME? COMPLETE?

Is there anything else you would like to add?

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