Medical History - Live for Better Health

Medical Health History

Name *

First

Middle

Last

Date

MM/DD/YYYY

AGE

Gender *

Phone Number *

###-###-####

Email *

Primary Address *

Street Address

Address Line 2 *

Address Line 2

City *

City

State *

State/Province/Region

Zip Code *

Postal/Zip Code

Country *

Country

BLOOD TYPE

BLOOD TYPE Rh Factor

HOSPITALIZATIONS

HOSPITALIZATION DATE(S) AND REASON(S)

DISEASES/DIGNOSIS/CONDITIONS

Check appropriate box(s).

Other Gastrointestinal Issue not listed

Other Cardiovascular Issue not listed

Other Metabolic/Endocrine Disorder Not listed

Other Cancer Not listed

Other Genital and Urinary System Dysfunction Not Listed

MUSCULOSKELETAL/PAIN *

Osteoarthritis
Fibromyalgia
Chronic Pain

Other Musculoskeletal/Pain Not Listed (copy)

Other Inflammatory/Autoimmune Not Listed

Other Respiratory Disease Not Listed

Other Skin Disease Not Listed

Other Neurological or Mood Disorders Not Listed

Date Preventive Tests Performed

Other Surgeries Not Listed and Dates of those Selected Above

INJURIES *

Back Injury
Neck Injury
Head Injury
Broken Bones

Other Injuries Not Listed and Dates of those Selected Above

GYNECOLOGIC HISTORY

For Women Only

AGE AT FIRST PERIOD

MENSES FREQUENCY AND LENGTH

PAIN

CLOTTING

HAS YOUR PERIOD EVER SKIPPED? IF SO, HOW LONG?

LAST MENSTRUAL PERIOD

MM/DD/YYYY

USE OF HORMONE CONTRACEPTION

Birth Control Pills
Patch
Nova Ring

HOW LONG?

IF OTHER.

LAST MAMMOGRAM

MM/DD/YYYY

BREAST BIOPSY

BREAST BIOPSY DATE

MM/DD/YYYY

LAST PAP TEST

MM/DD/YYYY

PAP TEST RESULTS

LAST BONE DENSITY

MM/DD/YYYY

BONE DENSITY RESULTS

ARE YOU IN MENOPAUSE

AGE OF MENOPAUSE

USE OF HORMONE REPLACEMENT THERAPY?

HOW LONG?

MEN'S HEALTH HISTORY

For Men Only

HAVE YOU HAD A PSA DONE?

PSA LEVELS

NOCTURIA: HOW MANY TIMES AT NIGHT

GASTROINTESTINAL HISTORY

GI History

FOREIGN TRAVEL?

HOW LONG?

WILDERNESS CAMPING?

WHERE?

HAVE YOU EVER HAD SEVERE:

Gastroenteritis
Diarrhea

DO YOU FEEL LIKE YOU DIGEST YOUR FOOD WELL?

DO YOU FEEL BLOATED AFTER MEALS?

PATIENT BIRTH HISTORY

Term
Premature

PREGNANCY COMPLICATIONS?

BIRTH COMPLICATIONS?

NOURISHMENT AS A BABY

IF BREAST FED, HOW LONG?

AGE INTRODUCED TO SOLID FOOD

AGE INTRODUCED TO DAIRY *

AGE INTRODUCED TO WHEAT *

Street Address

DID YOU EAT A LOT OF CANDY OR SUGAR AS A CHILD?

DENTAL HISTORY

IF SILVER MERCURY FILLINGS, HOW MANY?

DO YOU FLOSS REGULARLY?

MEDICATIONS AND SUPPLEMENTS

List All medications both Current and Past. All Supplements (Vitamins/Minerals/Herbs/Essential Oils/Homeopathy)

LIST DOSE AND FREQUENCY OF CURRENT MEDICATIONS

LIST DOSE AND FREQUENCY OF PAST MEDICATIONS

LIST CURRENT NUTRITIONAL SUPPLEMENTS