Health-form

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Health-form

    Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.

    Check Any Of the following Disease's have Had:

    • Pneumonia

    • Small Pox

    • Arthritis

    • Rheumatic Fever

    • Diabetes

    • Epilepsy

    • Polio

    • Cancer

    • Mental Disorder

    • Tuberculosis

    • Heart Disease

    • Eczema

    • Whooping Cough

    • Thyroid

    • Anemia

    • Pleurisy

    • Gout

    • Other

    • YesNo

    Health Habits:

    • Alcohol (>2 drinks per week)

    • Cigarettes

    • YesNo

    • ExcellentFairPoor

    Check Any Of the following Disease's have Had:

    • Low Back Pain

    • Pain between Shoulders

    • Neck PainShoulder Pain

    • Arm PainMid back Pain

    • joint Pain/Stiffness

    • Walking Problems

    • Difficult Chewing/Clicking Jaw

    • General Stiffness

    • Muscle Twitching/Spasms

    • Swollen joints

    • Pain Legs/Feet

    • Sciatica

    • NervousLoss of Balance

    • Numbness

    • Dizziness

    • Forgetfulness (Memory/Concentration)

    • Depression

    • Convulsions

    • Numb/Tingling Extremities

    • Stress

    • Fatigue/Low Energy

    • Allergies/Hay Fever

    • Loss of Sleep/Trouble Sleeping

    • Fever

    • Headaches

    • inner Tension/Stress

    • Irritability

    • Poor/Excessive Apetite

    • Excessive Thirst

    • Frequent Nausea

    • Vomiting Diarrhea

    • Constipation

    • Hemorrhoids

    • Liver Problems

    • Gall Bladder Problems

    • Weight Trouble

    • Abdominal Cramps

    • Indigestion

    • Gas/Bloating after Meals

    • Heartburn

    • Black/Bloody Stool

    • Colitis

    • Ulcers

    • Bladder Trouble

    • Painful/Excessive Urination

    • Discolored Urine

    • Kidney Trouble

    • Chest Pain

    • Shortness of Breath

    • High Blood Pressure

    • High Cholesterol

    • Irregular Heartbeat

    • Heart Problems

    • Lung Problems/Congestion

    • Varicose Veins

    • Ankle Swelling

    • Stroke

    • Asthma

    • Vision Problem

    • Dental Problems

    • Sore Throat

    • Ear Ache

    • Hearing Difficult

    • Sinus Trouble

    • Loss of Smell

    • Loss of Taste

    • Ringing in ears

    • Prostate

    • Sexual Dysfunction

    • body-chart

    • Please outline on the diagram the area of your discomfort.

    • The following members have the same or similar problem as I do;

    • Mother

    • Father

    • Brother

    • Sister

    • Spouse

    • Child

    • Menstrual Irregularity

    • Menstrual Cramps

    • Vaginal Pain/Infection

    • Breast Pain/Lumps

    • Other

    • When was your last period?
      Are you pregnant?

    • YesNoNot Sure