Name * First Name Last Name Date MM DD YYYY Email * Date of Birth Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### What is your Occupation * Sex Male Female Other Are you married? Yes No Do you have children? Yes No How many children? Personal History: Current Complaint When did your symptoms start? Have you ever had this before? Yes No What was happening around the time your symptoms started? Previous Complaints, Surgeries, Past conditions Other Conditions Check conditions you frequently experience: Allergies Headaches Cold Flu Depression Acid Reflux Constipation Diarrhea Skin Problems Ear aches Mood changes Dizziness Eye problems Fever Any other Complaints, Symptoms or conditions Family Health History Father Mother Paternal Grandfather, Paternal Grandmother Maternal Grandfather, Maternal Grandmother What are your fears? What are your worries? What are your food cravings? Foods you have a strong aversion to? Foods or drinks which cause you discomfort? Environmental Conditions Do you usually feel warm or cold? Yes No Do you usually feel better in warm or cool weather? Warm Cool Neither What time of the day you feel best, have most energy and can think clearly? Hour Minute Second AM PM What is your worst time of the day when you feel tired and /or irritable? Hour Minute Second AM PM Does disorganization bother you? Yes No Do you keep your home neat and tidy? Yes No Are you bothered by scary movies or unpleasant news on TV? Yes No What are you usually sensitive to? Noise Light Touch Smell Suffering of others Taste Anything else you are sensitive to? Do you prefer to keep your feelings to yourself or do you like to express them? to myself express them Do you experience angry outbursts? Yes No After you have lost control what do you feel? relieved remorseful guilty angry at yourself still angry upset Do you remeber injustices a long time? Yes No How does consolation from another person make you feel? Better Uncomfortable Nothing Do you have difficulty making decisions? Yes No Physical Traits When do you feel better? Doing things Sitting still What weather conditions make you feel better? Winter Sunny Cloudy Thunderstorm Lightning Humidity Snowfall Summer Rains What weather conditions are you most troubled by? Winter Sunny Cloudy Thunderstorm Lightning Humidity Snowfall Summer Rains When are you thirsty? Day Night Never Always How do you prefer your drinks? Cold Ice cold Hot Room temperature Bowel Habits Are you frequently constipated? Yes No Do you often have Diarrhea? Yes No Do you have abdominal bloating? Yes No Are you relieved by passing gas? Yes No Are you relieved by belching? Yes No Sleep Patterns Do you have difficulty falling asleep? Yes No Sometimes Do you have difficulty returning to sleep? Yes No Sometimes How do you feel while sleeping? Hot Cold Warm Restless In pain Sweaty Wonderful When you sleep at night you want the room to be? Warm Cool Quiet Dark Night lights on Describe your sleeping position: Do you cover yourself while sleeping? Describe the unusual dream you had as a child: Describe the unusual dreams you had recently: Do you feel worse in the morning? Yes No Somtimes The things that most concerns me is? I want most to have relief from? Women's Section At what age did your period begin? Was your period regular? Yes No Sometimes Is your period regular now? Yes No Sometimes How long does your period last? Have you ever had any major problems with your period? If so when? Please describe. Describe the quality of your period: color, clotting, etc. Current Medications Please list any current medications you are taking including supplements and/or herbs: Please list any past medicattions which you were on for a long time and/or you feel are still affecting you: Is there anything else you would like to share about your health? Please attach any health records you would like us to review. Congratulations you are done with this form. Appreciate your time. Go ahead and Submit it. Thank you! Health History Form