Health History & Information Form

NOTE INSTRUCTIONS: PLEASE TYPE IN YOUR INFORMATION AND PRINT IT OUT FOR FAXING TO AVOID DELAYS FROM IN-ABILITY TO READ ILLEGIBLE COPY. THANK YOU.


NameDate Of Birth: Today's Date:
Address:City:State:Zip
E-Mail: Confirm E-Mail:
Phone:Education Level Completed:Status: S M D W
Height:Weight:Occupation: BLOOD TYPE (circLe) A+,A- / B+,B- / AB-, AB+ / O+,O-
 

HOW DID YOU FIND US? REFERRED BY:

ARE YOU CURRENTLY UNDER A PHYSICIAN'S CARE? WHO, WHERE AND WHAT DIAGNOSIS? WHAT TREATMENTS HAVE BEEN DONE TO DATE ?


IN YOUR OWN WORDS, WHY ARE YOU SEEKING OUR SERVICES ? WHAT ARE THE PRIMARY THINGS YOU WANT ADDRESSED?


DIAGNOSTIC HISTORY: AS FAR BACK AS YOU CAN REMEMBER; CHECK ANY THAT HAVE EVER APPLIED TO YOU AND ESTIMATE DATE SINCE YOU FIRST EXPERIENCED IT; WRITE THE SPECIFICS NEXT TO IT.


ADDICTION / COMPULSIONS (Smoking, Alcohol, Street or Prescription Drugs, Gambling, Shopping, Food, Eating Disorders, etc.)
SINCE:DETAILS
ALLERGIES (Environmental, Food, Drugs, etc.)
SINCE: DETAILS
ANEMIA
SINCE:DETAILS
ANGINA
SINCE:DETAILS
ANOREXIA / BULIMIA
SINCE:DETAILS
ARTERIOSCLEROSIS
SINCE:DETAILS
ARTHRITIS
SINCE:DETAILS
ASTHMA
SINCE:DETAILS
BACK PAIN
SINCE:DETAILS
BLADDER (infections, cystitis, fallen, etc.)
SINCE:DETAILS
BLOOD DISORDER
SINCE:DETAILS
BLOOD SUGAR IMBALANCE
SINCE:DETAILS
BLOOD IN STOOLS
SINCE:DETAILS
BOWEL TROUBLE (Hemorrhoids, Inflammatory bowel (IBS), Crones', Colitis, etc.)
SINCE:DETAILS
BREATHING DIFFICULTY (PULMONARY SYNDROMES LIKE CYSTIC FIBROSIS, ETC.)
SINCE:DETAILS
BRONCHITIS (CHRONIC)
SINCE:DETAILS
BRUISING EASILY (capillary fragility)
SINCE:DETAILS
CANCER / FIBROIDS
SINCE:DETAILS
CARDIOVASCULAR / PERIPHERAL VASCULAR DISEASE
SINCE:DETAILS
CERVICAL DYSPLASIA
SINCE:DETAILS
CHRONIC FATIGUE SYNDROME / CME (CHRONIC MYEOLITIC ENCEPHALITIS)
SINCE:DETAILS
COLD HANDS/ FEET
SINCE:DETAILS
CIRCULATORY IMPAIRMENT
SINCE:DETAILS
COLDS, RESPIRATORY INFECTIONS (FREQUENTLY)
SINCE:DETAILS
CONSTIPATION (BOWEL MOVEMENTS LESS THAN 2X/ DAY)
SINCE:DETAILS
COORDINATION CHANGES
SINCE:DETAILS
CYSTITIS (CHRONIC BLADDER INFECTS W/SCARRING)
SINCE:DETAILS
DECREASED APPETITE
SINCE:DETAILS
DECREASED LIBIDO (sex drive)
SINCE:DETAILS
DEPRESSION
SINCE:DETAILS
DENTAL WORK (fill out in more detail below)
SINCE:DETAILS
DIABETES -- Mellitis Type (I) or Type II (adult onset / Syndrome X)
SINCE:DETAILS
DIGESTIVE PROBLEMS
SINCE:DETAILS
DRIBBLING URINE
SINCE:DETAILS
DRY SKIN/ ECZEMA / DERMATITIS
SINCE:DETAILS
EAR TROUBLE
SINCE:DETAILS
EDEMA (tissue swelling such fingers, face, ankles, etc.)
SINCE:DETAILS
EMOTIONAL or MOOD SWINGS
SINCE:DETAILS
ENLARGED LYMPH NODES
SINCE:DETAILS
EXCESSIVE SLEEP
SINCE:DETAILS
EMPHYSEMA
SINCE:DETAILS
EYE TROUBLE (vision)
SINCE:DETAILS
FATIGUE (does it resolve w/rest?)
SINCE:DETAILS
FIBROMYALGIA SYNDROME (Muscle pain with official differential diagnosis)
SINCE:DETAILS
FOOT PROBLEMS
SINCE:DETAILS
FREQUENT URINATION
SINCE:DETAILS
FEVERS
SINCE:DETAILS
GALLBLADDER
SINCE:DETAILS
GOUT
SINCE:DETAILS
HEADACHES
SINCE:DETAILS
HEART TROUBLE (includes arrhythmias, palpations, valve prolapse, congestive failure,etc.)
SINCE:DETAILS
HEARING TROUBLE
SINCE:DETAILS
HEMORRHOIDS
SINCE:DETAILS
HORMONE IMBALANCE (includes male, female, growth, insulin, growth, etc.)
SINCE:DETAILS
HOT FLASHES
SINCE:DETAILS
HYPOGLYCEMIA (Low Blood Sugar)
SINCE:DETAILS
HAIR LOSS
SINCE:DETAILS
HAIR GROWTH (EXCESS FACIAL HAIR, ETC.)
SINCE:DETAILS
INFECTIONS
SINCE:DETAILS
INCONTINENCE (URINARY)
SINCE:DETAILS
INSOMNIA
SINCE:DETAILS
IMMUNE DYSFUNCTION / LOW or AUTOIMMUNE
SINCE:DETAILS
INTESTINAL DISTRESS
SINCE:DETAILS
IRRITABILITY
SINCE:DETAILS
JOINT PAIN
SINCE:DETAILS
JOINT SWELLING
SINCE:DETAILS
KIDNEYS
SINCE:DETAILS
LIVER TROUBLE
SINCE:DETAILS
LOW BLOOD SUGAR / HYPOGLYCEMIA
SINCE:DETAILS
LUNG / PULMONARY TROUBLE
SINCE:DETAILS
LYMPHATIC CONGESTION/ SWELLING / PAIN
SINCE:DETAILS
MEMORY TROUBLE (describe onset of changes, short term, long term, etc.)
SINCE:DETAILS
MENSTRUAL CYCLE IRREGULARITIES / CHANGES
SINCE:DETAILS
MENTAL / EMOTIONAL DISTRESS
SINCE:DETAILS
MIGRAINE HEADACHES
SINCE:DETAILS
MUSCLE PAIN / WEAKNESS
SINCE:DETAILS
NERVE PAIN
SINCE:DETAILS
NUMBNESS / NEUROPATHY
SINCE:DETAILS
NIGHT SWEATS
SINCE:DETAILS
PROSTATE ENLARGEMENT (BPH)
SINCE:DETAILS
RHEUMATISM
SINCE:DETAILS
RASHES
SINCE:DETAILS
SCLERODERMA
SINCE:DETAILS
SKIN CONDITION
SINCE:DETAILS
STROKE(S) / TIA (transient ischemic attacks)
SINCE:DETAILS
SHORTNESS OF BREATH
SINCE:DETAILS
TREMORS (UNCONTROLLED SHAKEY HANDS, LEGS, etc.)
SINCE:DETAILS
TMJ (jaw joint pain)
SINCE:DETAILS
THYROID
SINCE:DETAILS
WEAK/ LETHARGIC (muscles don't recover; on-going chronic lethargy)
SINCE:DETAILS
WEIGHT GAIN
SINCE:DETAILS
WEIGHT LOSS
SINCE:DETAILS
OTHER______________________
SINCE:DETAILS
 

 
SURGERICAL HISTORY: i.e. C-sections, Cosmetic procedures, Appendectomy, Hysterectomy, Tonsillectomy, Dental surgeries, Prosthesis, Implants, etc.
Date:Surgery / Scar:
Doctor/Hospital Where Performed
Date:Surgery / Scar:
Doctor/Hospital Where Performed
Date:Surgery / Scar:
Doctor/Hospital Where Performed
Date:Surgery / Scar:
Doctor/Hospital Where Performed

 
INFECTIOUS DISEASE HISTORY: Check Only Applicable Infections
 INFECTION TYPE
WHEN

DETAILS / TREATMENT
 Candida Yeast
 
 Chicken Pox  
 
 Coxackie Virus
 
 
 Clamydia
 
 
 Cytomegalovirus Virus (CMV)
 
 
 Diphtheria
 
 
 Encephalitis
 
 
 Epstein Barr Virus (mono)
 
 
 Fungal Infections
 
 
 German Measles (Rubella)
 
 
 Gonorrhea
 
 
 Haunta Virus
 
 
 Herpes Virus I,II,Simplex
 
 
 Hepatitis A,B,C,E,G
 
 
 HHV6,7,8 (Roseola)
 
 
 HIV 1-17
 
 
 Human Papilloma (HPV) Virus
 
 
 Influenza
 
 
 Leishmoniasis
 
 
 Legionairres
 
 
 Lymes (spirochete)
 
 
 Malaria (babesia)
 
 
 Measles (Roseola, HHV6,7)
 
 
 Meningitis
 
 
 Mycoplasma (any)
 
 
 Parasites (worms, amoeba, etc.)
 
 
 Pleurisy
 
 
 Pneumonia
 
 
 Rheumatic Fever
 
 
 Scarlet Fever / scarlentina
 
 
 Shingles
 
 
 Small Pox
 
 
 Swine Flu
 
 
 Syphilis
 
 
 Toxoplasmosis
 
 
 Tuberculosis
 
 
 Typhus
 
 
 OTHER __________________
 
 
 

 
TRAUMA HISTORY: Injuries (Accidents, Broken bones, Lacerations, Head traumas, etc.). Intense Emotional Stress: : family member long term care giving in illness, death, loss of job, law suits, violence or sexual abuse, divorces, business failure; abduction, robbery, etc.)
Date:Event:
Method of Handling (therapy, morning, reconciliation, etc.)
Date:Event:
Method of Handling (therapy, morning, reconciliation, etc.)
Date:Event:
Method of Handling (therapy, morning, reconciliation, etc.)

 
DENTAL HISTORY List any type of work including fillings, root canals, bridges, pullings, abscesses, etc.
Date:Work:
Date:Work:
Date:Work:
Date:Work:
Date:Work:
Date:Work:
Date:Work:

 
VACCINATION HISTORY: ( Include vaccines for overseas travel, flu, military, etc.) includes tetanus, MMR, Flu shots, Typhus, Hep B, etc.
Date:Description:
Date:Description:
Date:Description:
Date:Description:
Date:Description:
Date:Description:
Date:Description:
Date:Description:

 
TRAVEL HISTORY (Include location, date & how long you stayed)
Date:Description:
Date:Description:
Date:Description:
Date:Description:
Date:Description:
Date:Description:
Date:Description:

 
FAMILY HISTORY (Blood-related siblings, grandparents, aunts, uncles, etc. If Deceased, cause? )
MATERNAL
PATERNAL

 
ENVIRONMENTAL ISSUES: Have you ever worked with Chemicals (hair salon, paint , refinishing furniture, mining, auto repair, construction, dental assistants, etc.? Do you live near a Toxic Waste Site? Power Plant, Sewage Plant or Nuclear Plant or Research Labratory? Have you ever smelled or seen mold s growing in damp areas around your home or business such as in basements or air conditioning ducts ? )
WHAT TYPE OF WATER DO YOU USE? (be sure to figure water you cook with like for making coffee, etc. as well as shower or bathe with)
Reverse OsmosisDistilledTap WaterFiltered Tap (Britta, etc.)Bottled Spring Well Water
 
PETS & LIVESTOCK ? DO YOU LIVE OR WORK IN AGRICULTURE ? (list cats, dogs, horses, chickens, ducks, geese, cattle, birds, rodents, turtles, etc.--Either your own or other people's whom you watch. Do you use a kennel ? Do you have any rodent infestations such as rats, mice, etc?)
 
E.M.F. EXPOSURE Cellular Phones, Wireless Phones, Wireless Devices (hand-helds), Laptops, Desktop computer, High Risk Work-related exposures...electronic & computer technicians, carpenters, pilots, microwave engineers, etc. Electronic Equipment at the workplace such as used in Manufacturing Plants, Nuclear Medicine, Dental Industry, Airline Industry, etc. . . .
 

 
SUPPLEMENTS & RX MEDICATIONS: Include Over the Counter Things also. What you take, Why you take them, How you take them.

 
ALLERGIES / Immune Reactions (List foods, pet, environmental, chemical, drug, supplements, etc.)

ARE YOU NOW OR HAVE EVER BEEN A SMOKER ? (this includes marajuana, cigarettes, or chewing tobacco) YESNO
DETAILS:

 
WOMEN ONLY:
DATES OF LAST MENSTRUAL CYCLE # DAYS
ARE YOU MENOPAUSAL? YESNO
IF YOU'RE MENOPAUSAL, DID YOU HAVE A HYSTERECTOMY OR PARTIAL? YESNO
DESCRIBE:
HAVE YOU EVER HAD FIBROIDS OR FIBROCYSTIC BREASTS OR OVARIES YESNO
DETAILS:
ARE YOU NOW OR HAVE YOU EVER USED BIRTH CONTROL PILLS? YESNO
IF YES, HOW LONG, TYPE, ETC.?
HAVE YOU EVER HAD AN EARLY TERMINATED PREGNANCY ? YESNO
YOUR AGE AT THE TIME:HOW MANY WEEKS (Gestation) ?
ANY PROCEDURES DONE OR COMPLICATIONS ?
DESCRIBE HOW YOU RECOVERED:
HAVE YOU EVER EVALUATED FOR AN STD ? (herpes, HPV, clamydia, etc.) YESNO
DESCRIBE TREATMENT:

PERSONAL / SOCIAL HISTORY (This is completely confidential...just so I can get to know you better ...)

CURRENT OCCUPATION:SINCE
MARRIED? YES NO IF YES, HOW LONG?
IS THE RELATIONSHIP SUPPORTIVE & HEALTHY?
IF DIVORCED, HOW LONG? AMICABLE ?
CHILDREN? YESNO AGES:
CHILDREN LIVE PRIMARILY WITH?
UNMARRIED PARTNERS YESNO FOR HOW LONG?
IS THE RELATIONSHIP SUPPORTIVE & HEALTHY?
HOMOSEXUAL OR BISEXUAL RELATIONSHIPS?HOW LONG?
ANY SPIRITUAL AFFILIATION OR FAITH? YESNO DETAILS:
DO YOU CONSIDER YOURSELF ACTIVELY PRACTICING? YESNO
 
ADDITIONAL PERSONAL INFORMATION YOU FEEL WE NEED THAT WOULD BE HELPFUL TO HELP US GET TO KNOW YOU: (HOBBY'S, MUSICAL INTERESTS, PASSIONS IN LIFE, ETC.)
 

PHYSICAL ACTIVITY LEVEL ON A WEEKLY BASIS: (please check what is your normal weekly level, not your best)

1. NOT SO MUCH: DISABLED OR TOO ILL / DISLIKE / DON'T TAKE TIME
2. INFREQUWENTLY ... COUCH or COMPUTER POTATO / OFFICE COMMUTER. LIGHT YARD WORK OR WALKS OCCASSIONALLY.
3. INTERMITTENT: BREAK A SWEAT FOR 30+ MINUTES, INTERMITTENTLY THROUGHOUT THE MONTH (Yardwork, Hikes, etc.)
4. WEEKY: AEROBICS, WEIGHTS, HOME GYM, RACKETBALL, TENNIS, etc. 45+ MIN. AT LEAST 3 TIMES WEEKLY
5. REGULARLY INTENSIVE: CONSTRUCTION, SPORTS, RUNNERS, HIKERS, DANCER, BIKER, OR WORKOUTS 1+ HR. 5 X WEEK OR MORE
 

DO YOU SWEAT WHEN HOT OR WITH EXERTION ? YESNO
IF NO, DESCRIBE DETAILS:
 
DIET & NUTRITION : TELL ME WHAT YOU EAT , HOW OFTEN, AND HOW MUCH, USUALLY IN A GIVEN WEEK OR DAY. BE SURE TO INCLUDE SNACKS, COFFEE, TEA, ETC. PLEASE BE SURE TO INCLUDE THINGS LIKE SODAS, STARBUCKS, ETC.
 

©1994-2007 Arrowhead HealthWorks ™ P.O.Box 3668, Crestline, CA 92325
(909) 338-3533 / FAX (909) 338-3743
E-mail: dbormann@arrowheadhealthworks.com *ARROWHEADHEALTHWORKS.COM