Living situation: Alone/Friends/Partner/Spouse/Parents/Children/Pets
What are your major health concerns and/or intentions?
Please list other health
care providers/consultants you are currently working with.
Please list any health conditions diagnosed by a medical
doctor.
Please list all herbs, vitamins and dietary supplements you are currently taking.
Family History
Please describe any relevant or major health related issues such as cancer, mental
illness, diabetes, heart disease, stroke, etc.
Medical HistoryList
all major health problems including any operations and year.
What was the date of your last physical exam?
Please list approximate dates and describe the nature of any traumatic experiences
you have had in the past 7 years, such as divorce, surgery, end of a relationship, loss of a job, death of a loved
one, change of residence, injury, etc.
Please check all that describe you
I am often not
able to express my emotions
I am dissatisfied with my job
I am often stressed out and not able to cope properly
Even though I'm in a relationship, I often feel lonely
I often feel anxious and nervous for no good reason
I
tend to see the good in people
I have a great sense of humor and love a good joke
I receive great joy from my family
My outlook on life is positive
My job uses all my greatest talent
I have plenty of energy to do all the things
I want
I am able to express anger constructively
I practice meditation or other relaxation techniques
Lifestyle
Do you engage in regular physical activity? What type?
How many minutes?
Does anyone smoke in your home?
How many hours of television do you watch per week?
What
is your occupation?
How would you describe your job:
Physical/Mental/Stressful/Easy-going/Secure/Non-Secure/Exhausting/Relaxing
Miscellaneous
Height / Weight / Weight one year ago / Desired weight
Do
you currently have any silver/amalgam fillings in your teeth?
3 Day Nutritional Analysis
Please write down everything you
eat and drink for the next three days as accurately as possible. Include coffee, alcoholic beverages, soda, candy bars,
etc., and estimated serving sizes.
Is the above an accurate representation of your overall diet?
Do you regularly
drink alcohol? How much? How often
Do you eat breakfast on a regular basis?
How many glasses of purified water
do you drink every day?
How many servings of low fat protein (beans, fish, skinless chicken breast) do you eat every day?
How
many cups of coffee, soda, or black tea do you drink every day?
How many fast food items (hamburgers, tacos, hot dogs,
French fries, etc) do you eat every day?
How many servings of dairy (milk, cheese, cream, yogurt, ice cream, pudding,
etc) do you eat every day?
