Welcome to our office.
It’s an honor to be of service to you.
Please complete the following confidential health history.
* Denotes a Required Field
        
Name:*
Preferred name:
Address:*
 
City:*
State:*
Zip:*
At least one phone number is required.
Home phone number:
Work phone number:
Cell phone number:
E-mail:*
Male/Female:*
 Male Female
Birth date:*
Age:*
Your occupation:*
Emergency contact:*
Relationship:*
Phone number:*
Whom may we thank for referring you to us?

For Insurance Purposes:
Marital Status:*
 Single Married Divorced Widowed
Primary insurance
Name of insurance company:*
Contract number: *
Group number: *
Is your insurance policy under your name?*
 Yes No
If not, whose name is it under?
What is your relationship to this person?
Birth date of insured:
Phone number of insurance company (on back of card):*
Address of the insurance company (on back of card):*
Secondary insurance
Name of insurance company:
Contract number:
Group number:
Is your insurance policy under your name?
 Yes No
If not, whose name is it under?
What is your relationship to this person?
Birth date of insured:
Phone number of insurance company (on back of card):
Address of the insurance company (on back of card):

Health History:

Section 1
Is this your first chiropractic experience? Yes No
If no, please describe your past care:
Is this your first clinical nutrition experience? Yes No
If no, please describe your past care:

List your previously diagnosed health issue/s.
For example: diabetes, high blood pressure, IBS, etc…
Health Issue 1:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 2:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 3:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 4:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 5:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Others:

List your surgeries.
1.  
2.  
3.  
4.  
5.  
Others:


List any supplement/s, vitamin/s, herb/s, homeopathic/s, medication/s you are taking and the reason for which you are taking them:
1.  
      Reason:  
2.  
      Reason:  
3.  
      Reason:  
4.  
      Reason:  
5.  
      Reason:  
Others:

Please list your health concern/s in order of severity:
First concern*
When did this start?*
How did this start? Was there a specific event?*
Was it a sudden or gradual onset?*
How does it feel?*
If there is pain, does it stay in one place or does it travel?*
If it travels where does it travel to?*
What makes it feel better?*
What makes it feel worse?*
What time of the day is it better?*
What time of the day is it worse?*
What do you think is the cause of this?*
What other test/s, procedure/s have you had in regards to this issue?*
What have been the results of this/these procedure/s?*

Is there anything else you would like to mention regarding this issue?

Second concern
When did this start?
How did this start? Was there a specific event?
Was it a sudden or gradual onset?
How does it feel?
If there is pain, does it stay in one place or does it travel?
If it travels where does it travel to?
What makes it feel better?
What makes it feel worse?
What time of the day is it better?
What time of the day is it worse?
What do you think is the cause of this?
What other test/s, procedure/s have you had in regards to this issue?
What have been the results of this/these procedure/s?

Is there anything else you would like to mention regarding this issue?

Third concern
When did this start?
How did this start? Was there a specific event?
Was it a sudden or gradual onset?
How does it feel?
If there is pain, does it stay in one place or does it travel?
If it travels where does it travel to?
What makes it feel better?
What makes it feel worse?
What time of the day is it better?
What time of the day is it worse?
What do you think is the cause of this?
What other test/s, procedure/s have you had in regards to this issue?
What have been the results of this/these procedure/s?

Is there anything else you would like to mention regarding this issue?


Lifestyle:
Alcohol*   
None Daily Weekly Monthly
Coffee*   
None Daily Weekly Monthly
Soda*   
None Daily Weekly Monthly
Sweets/Refined Carbohydrates* 
None Daily Weekly Monthly
Soy Products*   
None Daily Weekly Monthly
Protein*   
None Daily Weekly Monthly
Fresh Fruits/Veggies*   
None Daily Weekly Monthly
White Flour*   
None Daily Weekly Monthly
Milk/Dairy*   
None Daily Weekly Monthly
Juice*   
None Daily Weekly Monthly
Meat/Fish*   
None Daily Weekly Monthly
 
Are you vegetarian?*
Yes No
If yes, please explain
 
We have on staff a certified nutritionalist. Would you like to be contacted for a personalized review of your diet and meal planning strategies?*
Yes No
 
Do you smoke cigarettes/cigars, use nicotine gum, or chew tobacco?*
Yes No
If yes, please explain
If you do not smoke, do you live in a household where smoke is present?
Yes No
How would you rate your stress level?*
None 1 2 3 4 5 6 7 8 9 10 Extreme
How would you rate your stress handing?*
Poor 1 2 3 4 5 6 7 8 9 10 Excellent
How would you describe your job?* Check all that apply.
          Physical
          Mental
          Stressful
          Exhausting
          Relaxing
          Secure
          Non-secure
How many hours do you work in an average week?*
How often do you exercise?*
Never Rarely Sometimes Regularly Competatively
Sleep Habits
How do you sleep?*
Well Trouble Falling Asleep Trouble Staying Asleep Insomnia
If you do not sleep well, how long has this been going on?
How many hours do you sleep a night on average?*
Do you wake up tired?*
Yes No
If yes, how long has this been happening?

Section 2 (Women Only)
Answer "yes" to anything that applies to you; no check assumes the answer is no.
What was the date of your last physical?
Were there any unusual findings?
What is the date of your last pelvic/GYN examination?
Pap Test? Mammogram? Thermography?
Where there any unusual results?
Age at onset of menarche
(first period):
Approximate date of onset:
Are you currently using a method of birth control? Yes
If yes, what method?
Have you used any of the following contraceptives in the past? Check all that apply.
          Oral
          Injected
          Patch
          Ring
          "Day after Pill"
When were these methods used and for how long?
Have you used, or are you currently using an IUD? Yes
If yes, was/is it a copper, hormone, or other type of IUD?
Please describe any problems that may have been associated with the use of any birth control methods (ie: yeast, infection, odor, heavy/light bleeding, mood, weight gain, acne, sweet cravings, fatigue, depression, palpitations etc…)
Have you used, or are you currently using fertility treatment?   Yes
If yes, please explain.
Have you used, or are you currently using conventional hormone replacement
therapy (HRT)?   Yes
If yes, please explain.
Have you used, or are you currently using bio-identical hormone creams/gels/sublingual, troche, oral?   Yes
If yes, please explain.
Are you currently pregnant?
 Yes
If yes, when are you due?
Are you currently nursing?
 Yes
Have you been pregnant before?
 Yes
If yes, what was the number of pregnancies?  
      Live Births?  
    Miscarriages?  
What is/are the age/s of your child/ren?
Were there any complications during the pregnancy and/or delivery?   Yes
If yes, please explain.
If you have had a miscarriage, how many weeks pregnant were you?
Have you had a vaginal infection?
Yes
If yes, what kind?
What treatment and/or medication were given?  
Have you had any history of the following?
      Fibrocystic Breast Yes
      Ovarian Cysts Yes
      Polycystic Ovarian Syndrome (PCOS) Yes
      Uterine Fibroids Yes
      Endometriosis Yes
Signs & Symptoms
Anxiety/Nervousness/Irritable
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Mood swings
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Overly Reactive/Short fuse/Anger
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Low Mood/Depression
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Low Blood Sugar/High Blood Sugar
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Lowered self-esteem/self-image
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Care for others before yourself
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Sadness/Crying
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Trouble Concentrating
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  

Memory difficulties
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Fatigue/Low energy
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Slow starter in morning
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Insomnia
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Wake up more tired than went to bed
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Nausea/Lightheaded/Dizzy
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Increased appetite/Constant hunger
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Sweet cravings/Carbs/Chocolate
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Caffeine/Stimulant cravings
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Salt cravings
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Headaches/Migraines
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Muscle pain/Joint aches/Backache
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Weight gain/Trouble
losing weight
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Weight loss
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Water retention
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Bloating/Belching/Gas
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Stomach burning/Nausea/Indigestion
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Constipation
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Loose stool/Diarrhea/IBS
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Light-colored stool
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Acne/Rashes/Brown spots
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Excessive facial hair/body hair
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Body/Head hair loss
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Infertility
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Lowered libido/Heightened libido
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Hot flashes/Night sweats
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Heart/Chest palpitations
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Breast tenderness/
Breast cysts
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Nipple discharge
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Vaginal infections/Yeast infections
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Urinary frequency/
Incontinence/Infections
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Dry eyes/Dry skin/
Overall dryness
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Changes to Labia/
Clitoral tissue (atrophy, discoloration, itching, burning)
 Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
Vaginal changes (dryness, tearing, decreasing size)
Yes
On-going Just with period
Mild Moderate Severe
Additional comments:  
 
For Cycling Women (If you are not cycling, please go to the next section.)
What was the first day of your last menstrual period?     
Have you had a tubal ligation?   Yes   If yes, when?  
How many days is your current cycle? (This number is calculated from the first day of your period to the first day of your next period).  
 Less than 20 20–30 30–40
40–50 More than 50
How many days does your menstruation typically last?     
Is your cycle regular?
Yes No Sometimes
If no or sometimes, please explain.
What is your typical menstrual flow?     Light Medium Heavy
How many pads and/or tampons are used on heavy days?
       Pads       Tampons   
Do you pass clots?     Yes     If yes, how often? 
Do you spot?    Yes     If yes, please explain.  
Do you experience cramping?   None Mild Moderate Severe  
If yes, at what point in your cycle?  
Do you experience abnormal vaginal discharge?   Yes    
       If yes, when? 
Do you experience vaginal itching and/or odor?     Yes    
       If yes, when? 
Do you experience breast tenderness?   None Mild Moderate Severe  
If yes, at what point in your cycle?  
During your cycle is there a change in breast size?   Yes
During your cycle do you experience nipple discharge?   Yes
   If yes, when?     What is the color?  

Is there anything else you would like to share that you feel would be helpful
for us to know?
 
For Menopausal Women
What was your age at the onset of menopause?
Year of onset?


Have you had a hysterectomy?   Yes
If yes, was it a complete hysterectomy (ovaries AND uterus) or a partial hysterectomy? (uterus only). Choose one.     Complete Partial
What was the date of your hysterectomy?
What was the reason for your hysterectomy?


List any other GYN related surgeries:


Describe your experience transitioning into menopause (symptoms, strong emotions, thoughts, unusual stressors, etc.)


Have you had, or do you have any vaginal spotting or bleeding since menopause?
Yes        If yes, when?  
Were you evaluated and/or treated by a GYN?     Yes

When you were cycling...
How would you have described your menstruation?  
Easy Uncomfortable Difficult Debilitating  
What was your typical menstrual flow?     Light Medium Heavy
When you were cycling would you have considered your cycle regular? Yes
If no, explain.  
Please describe any “treatment” ever received for cycle issues.


Is there anything else you would like to share that you feel would be helpful
for us to know?
 
designed by root & branch