Health Questionaire

Please complete all required fields!

Your Information

First Name

Please type your full name.

Last Name

Invalid Input

E-mail

Invalid email address.

Date of Birth

Day01020304050607080910111213141516171819202122232425262728293031 / Month010203040506070809101112 / Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 Invalid Input

Address

Invalid Input

City

Invalid Input

Province

Invalid Input

Postal Code

Invalid Input

Home Phone

Invalid Input

Work Phone

Invalid Input

Mobile Phone

Invalid Input

Married?

Yes No Invalid Input

Referred By?

Invalid Input

Occupation

Invalid Input

Next >

Physician Information

First Name

Invalid Input

Last Name

Invalid Input

Physicians Phone

Invalid Input

Address

Invalid Input

City

Invalid Input

Province

Invalid Input

Postal Code

Invalid Input

Emergency Contact

First Name

Invalid Input

Last Name

Invalid Input

Phone

Invalid Input

< PrevNext >

Medical / Physical Questions

Please describe your Main Complaint (symptoms, duration, prior treatments, etc.)

Invalid Input

What makes your condition(s) better? (movement, sleep, heat, cold, eating, meditation, etc.)

Invalid Input

What makes your condition(s) worse? (stress, rainy days, foods, hunger, tired, heat, etc.)

Invalid Input

Allergies and Environmental Exposures (food, plant, chemical, metal, drugs, etc.)

Invalid Input

Significant Trauma (physical or emotional)

Invalid Input

Surgeries (date/s)

Invalid Input

Current Medications (dosages and names of product)

Invalid Input

Exercise (Days/week) - Type of Exercise - Duration of workout

Invalid Input

Diet (Meals/day) - Time of meals - Snacks (per day) - Alcohol (drinks/week) - Caffeine (drinks/day)

Invalid Input

What Vitamins, Supplements, or Herbs have you taken? What results?

Invalid Input

< PrevNext >

Detailed History

Please check any existing conditions or symptoms you have now

Arthritis
Liver/Gall Bladder Disease
Stroke
Heart Disease
High/Low Blood Pressure
Hypo/Hyperglycemia
Kidney Disease
Elevated Blood Cholesterol
Cancer
Diabetes
Food Allergies/Intolerance
Diverticulitis/IBS
Ulcer
Seizures

Hepatitis
Raynaud’s Disease
Chronic Fatigue
Anemia
Thyroid Imbalance
Respiratory Allergies
Alcoholism
Lyme Disease
Chronic Pain Condition
Impotence
Gastritis/Pancreatitis
Asthma
Infertility
Emphysema

Invalid Input

Family Medical History

Seizures
Allergies
Heart Disease
Cancer
Diabetes
High Blood Pressure
Stroke
Asthma
Other Invalid Input

If you selected other, please explain

Invalid Input

< PrevNext >

Please Check if you have had any of these items listed below in THE LAST YEAR

General

Poor Sleeping
Chills
Fevers
Bleed/Bruise easily
Muscle fatigue/weakness
Night Sweats
Poor Appetite
Localized Weakness
Weight loss/gain
Sudden energy drop
Fatigue
Sweats Easily
Poor Balance
Peculiar tastes/smells
Strong thirst
Cravings
Tremors
Change in appetite
Dental/gum problems
Lack of thirst Invalid Input

Gastrointestinal

Nausea
Vomiting
Indigestion
Bloating/Edema
Changes in appetite
Excessive appetite
Gas
Belching
Bad breath
Chronic laxative use
Acid reflux/GERD
Significant thirst
Diarrhea
Black stools
Rectal pain
Loose stools (>2 per day)
Hernia
IBS / Crohn’s Disease
Constipation
Blood in stool
Hemorrhoids
Abdominal pain/cramps
Poor appetite Invalid Input

Genito-Urinary

Frequent urination
Pain on urination
Blood in urine
Urgent urination
Kidney stones
Unable to hold urine
Scanty flow
Copious flow
Impotence
Sores on genitals
Urinary tract infection
Burning urination
Premature ejaculation
Decreased libido
Prostatitis
Dribbling after urination
Nocturnal emission
Pain in testicles
Herpes
Infections
Excessive libido Invalid Input

Night Urination: What times and how often per night?

Invalid Input

Respiratory

Cough/Wheezing
Coughing blood
Asthma
Bronchitis
Pneumonia
Pain with deep inhalation
Tight sensation in chest
Difficult inhale/exhale
Difficulty breathing when lying down Invalid Input

Production of phlegm (amount/colour)

Invalid Input

Cardiovascular

Chest pain or pressure
Irregular heart beat
Palpitations at rest
Fainting
Cold hands/feet
Swelling of hands/feet
Blood clots
Phlebitis
Shortness of breath
Varicose/spider veins
Pressure in chest
High blood pressure
Low blood pressure
Spontaneous sweating
Dizziness Invalid Input

Head, Eyes, Ears, Nose and Throat

Dizziness
Difficulty swallowing
Migraines
Glasses
Eye Strain
Eye pain
Poor vision
Night Blindness
Color Blindness
Cataracts
Blurred vision
Earaches
Ringing in ears
Poor hearing
Spots in front of eyes
Sinus problems
Nose bleeds
Recurrent sore throats/colds
Grinding teeth
Facial pain
Sores on lips/tongue
Dental problems
Jaw clicks/locks
Headaches Invalid Input

Musculoskeletal

Neck pain
Shoulder pain
Hand/wrist pain
Carpal Tunnel
Knee pain
Sprains/Strains
Sciatica Foot/ankle pain
Hip pain
Muscle pain
Muscle weakness
Tendonitis
Back pain Low
Back pain Middle
Back pain Upper
Bursitis
Rotator Cuff
Soreness/weakness in lower body (back, knee, hip, ankle, foot) Invalid Input

Skin and Hair

Rashes Ulcerations
Hives/Allergic
Dermatitis Itching
Eczema/Psoriasis
Dandruff
Loss of hair
Recent moles
Skin discoloration
Acne
Change in skin/hair texture
Face flushing
Dermatitis Warts
Fungal Infection
Weak or ridged nails Invalid Input

Gynecological/Reproductive

Vaginal dryness
Ovarian cysts
Vaginal sores
Endometriosis
Vaginal discharge
Uterine Fibroids
Difficult/Painful intercourse
Fibrocystic breast tissue
Infertility
Polycystic Ovarian Disease
Irregular menstruation
PMS
Painful menstruation
Do you practice birth control? Invalid Input

What type of birth control have you taken?

Invalid Input

Age of first menses?

Invalid Input

Date of last menses?

Invalid Input

How long did/have you taken birth control?

Invalid Input

Date of last PAP/Pelvic?

Invalid Input

Number of pregnancies?

Invalid Input

Number of ectopic pregancies?

Invalid Input

Number of live births?

Invalid Input

Number of miscarriages?

Invalid Input

Number of abortions?

Invalid Input

Neuropsychological

Seizures
Loss of balance
Vertigo/Dizziness
Areas of numbness
Lack of coordination
Poor memory
Concussion Depression
Anxiety/Panic attacks
Bad temper/irritable
Easily susceptible to stress
Seasonal Affective Disorder
Nervousness
ADD/ADHD
Manic Depression
Have you ever been treated for emotional problems?
Have you ever considered or attempted suicide?
Have you ever been treated for substance abuse? Invalid Input

Comments Please inform me of any other problems you would like to discuss.

Invalid Input

< PrevSubmit Reset