Name
Invalid Input

Date
Invalid Input

Address
Invalid Input

City
Invalid Input

State
Invalid Input

Zip Code
Invalid Input

Preferred Contact Number
Invalid Input

Email Address
Invalid Input

Emergency Contact
Invalid Input

Emergency Number
Invalid Input

Date of Birth
Invalid Input

Age
Invalid Input

Gender
Invalid Input

Occupation
Invalid Input

Employer
Invalid Input

Please identify the health concerns that have brought you here in order of importance below:

Condition
Invalid Input

Past Treatment
Invalid Input

How does this condition affect you?
Invalid Input

Condition
Invalid Input

Past Treatment
Invalid Input

How does this condition affect you?
Invalid Input

Condition
Invalid Input

Past Treatment
Invalid Input

How does this condition affect you?
Invalid Input

Condition
Invalid Input

Past Treatment
Invalid Input

How does this condition affect you?
Invalid Input

Please list any foods, medications or environmental substances you are hypersensitive / allergic to and their reactions:
Invalid Input

Please list any medications (prescribed or over the counter), vitamins, herbs or supplements you are currently taking:
Invalid Input

Do you have any infectious diseases
Invalid Input

If yes, please identify:
Invalid Input

Family History

Self

xxxxx

Age ( if living )
Invalid Input

Health
Invalid Input

Cancer
Invalid Input

Diabetes
Invalid Input

Heart Disease
Invalid Input

High Blood Pressure
Invalid Input

Stroke
Invalid Input

Mental Illness
Invalid Input

Asthma/Allergies
Invalid Input

Kidney Disease
Invalid Input

Age at Death
Invalid Input

Cause of Death
Invalid Input

Father

xxxxx

Age ( if living )
Invalid Input

Health
Invalid Input

Cancer
Invalid Input

Diabetes
Invalid Input

Heart Disease
Invalid Input

High Blood Pressure
Invalid Input

Stroke
Invalid Input

Mental Illness
Invalid Input

Asthma/Allergies
Invalid Input

Kidney Disease
Invalid Input

Age at Death
Invalid Input

Cause of Death
Invalid Input

Mother

xxxxx

Age ( if living )
Invalid Input

Health
Invalid Input

Cancer
Invalid Input

Diabetes
Invalid Input

Heart Disease
Invalid Input

High Blood Pressure
Invalid Input

Stroke
Invalid Input

Mental Illness
Invalid Input

Asthma/Allergies
Invalid Input

Kidney Disease
Invalid Input

Age at Death
Invalid Input

Cause of Death
Invalid Input

Brothers

How Many
Invalid Input

Age ( if living )
Invalid Input

Health
Invalid Input

Cancer
Invalid Input

Diabetes
Invalid Input

Heart Disease
Invalid Input

High Blood Pressure
Invalid Input

Stroke
Invalid Input

Mental Illness
Invalid Input

Asthma/Allergies
Invalid Input

Kidney Disease
Invalid Input

Age at Death
Invalid Input

Cause of Death
Invalid Input

Sisters

How Many
Invalid Input

Age ( if living )
Invalid Input

Health
Invalid Input

Cancer
Invalid Input

Diabetes
Invalid Input

Heart Disease
Invalid Input

High Blood Pressure
Invalid Input

Stroke
Invalid Input

Mental Illness
Invalid Input

Asthma/Allergies
Invalid Input

Kidney Disease
Invalid Input

Age at Death
Invalid Input

Cause of Death
Invalid Input

Blood Pressure

Blood Pressure: What is your most recent reading
Invalid Input

When was this reading?
Invalid Input

Your height
Invalid Input

Your current weight
Invalid Input

Childhood Illnesses
Invalid Input

Other Illnesses
Invalid Input

Immunizations
Invalid Input

Other Immunizations
Invalid Input

Hospitalizations and Surgeries

Reason
Invalid Input

When
Invalid Input

Reason
Invalid Input

When
Invalid Input

Reason
Invalid Input

When
Invalid Input

Reason
Invalid Input

When
Invalid Input

In this section please select any symptoms/conditions you experience now and underline any you have experienced in the past:

Emotional

Experienced Now

Experienced in the Past

Mood Swings
Invalid Input

Nervousness
Invalid Input

Mental Tension
Invalid Input

Depression
Invalid Input

Anxiety
Invalid Input

Stress
Invalid Input

Energy and Immunity

Fatigue
Invalid Input

Slow Wound Healing
Invalid Input

Chronic Infections
Invalid Input

Chronic Fatigue Syndrome
Invalid Input

Head, Eye, Ear, Nose and Throat

Impaired Vision
Invalid Input

Eye Pain/Strain
Invalid Input

Glaucoma
Invalid Input

Glasses/Contacts
Invalid Input

Tearing/Dryness
Invalid Input

Impaired Hearing
Invalid Input

Ear Ringing
Invalid Input

Headaches
Invalid Input

Sinus Problems
Invalid Input

Nose Bleeds
Invalid Input

Frequent Sore Throats
Invalid Input

Teeth Grinding
Invalid Input

TMJ/Jaw Problems
Invalid Input

Hay Fever
Invalid Input

Respiratory

Pneumonia
Invalid Input

Frequent Colds
Invalid Input

Difficulty Breathing
Invalid Input

Persistent Cough
Invalid Input

Shortness of Breath
Invalid Input

Other Respiratory Problems
Invalid Input

Cardiovascular

Heart Disease
Invalid Input

Chest pain
Invalid Input

Swelling of Hands or Feet
Invalid Input

High Blood Pressure
Invalid Input

Palpitations/ Flutter
Invalid Input

Stroke
Invalid Input

Heart Murmurs
Invalid Input

Varicose Veins
Invalid Input

Rheumatic Fever
Invalid Input

Other Cardiovascular Problems
Invalid Input

Gastrointestinal

Ulcers
Invalid Input

Changes in Appetite
Invalid Input

Nausea/Vomiting
Invalid Input

Epigastric Pain
Invalid Input

Excess Gas
Invalid Input

Heartburn
Invalid Input

Gallbladder Disease
Invalid Input

Liver Disease
Invalid Input

Hepatitis
Invalid Input

Hemorrhoids
Invalid Input

Abdominal Pain
Invalid Input

Bloating
Invalid Input

Constipation
Invalid Input

Diarrhea
Invalid Input

Rectal Bleeding
Invalid Input

Genito-Urinary

Kidney Stones
Invalid Input

Kidney Disease
Invalid Input

Painful Urination
Invalid Input

Frequent Urination
Invalid Input

Blood in Urine
Invalid Input

Frequent Urinary Infections
Invalid Input

Frequent Urination at Night
Invalid Input

Female / Reproductive:

Do you have any reason to believe you might be pregnant?
Invalid Input

If so, how far along are you?
Invalid Input

Irregular Cycle
Invalid Input

Breast Lumps/Tenderness
Invalid Input

Heavy Periods
Invalid Input

Vaginal Discharge
Invalid Input

Menopausal Symptoms
Invalid Input

Premenstrual Problems
Invalid Input

Bleeding between Cycles
Invalid Input

Clotting
Invalid Input

Painful Periods
Invalid Input

Infertility
Invalid Input

When was last Pap Smear?
Invalid Input

Results
Invalid Input

Age of First Menses?
Invalid Input

# Days of Menses
Invalid Input

Length of Cycle
Invalid Input

Birth Control Type
Invalid Input

# of Pregnancies
Invalid Input

# of Miscarriages
Invalid Input

# of Live Births
Invalid Input

# of Abortions
Invalid Input

Male Reproductive

Sexual Difficulties
Invalid Input

Prostate Problems
Invalid Input

Testicular Pain/Swelling
Invalid Input

Penile Discharge
Invalid Input

Musculoskeletal

Neck/ Shoulder Pain
Invalid Input

Upper Extremity Pain
Invalid Input

Lower Extremity Pain
Invalid Input

Muscle Weakness
Invalid Input

Back Pain - Upper
Invalid Input

Back Pain - Mid
Invalid Input

Back Pain - Lower
Invalid Input

Joint Pain
Invalid Input

If so, where?
Invalid Input

Neurologic

Vertigo/Dizziness
Invalid Input

Paralysis
Invalid Input

Numbness/ Tingling
Invalid Input

Loss of Balance
Invalid Input

Seizures
Invalid Input

Endocrine

Hypothyroid
Invalid Input

Hyperthyroid
Invalid Input

Hypoglycemia
Invalid Input

Diabetes
Invalid Input

Night Sweats
Invalid Input

Other

Anemia
Invalid Input

Cancer
Invalid Input

Eczema/Hives
Invalid Input

Hot or Cold Hands/ Feet
Invalid Input

Is there anything else we should know?
Invalid Input

When was your last Complete Blood Count (Blood Work) done?
Invalid Input

Any abnormal Results?
Invalid Input

Lifestyle

Do you typically eat at least three meals a day?
Invalid Input

If no, how many?
Invalid Input

Do you exercise?
Invalid Input

If yes, how long/ how many days per week?
Invalid Input

How many hours per night do you sleep?
Invalid Input

Do you wake up during the night?
Invalid Input

Do you go back to sleep w/o problem?
Invalid Input

Do you wake up rested?
Invalid Input

Occupation
Invalid Input

How many hours per week do you work?
Invalid Input

Employer's Name
Invalid Input

Nicotine/Alcohol/Caffeine Use
Invalid Input

Have you experienced any major trauma?
Invalid Input

Explain
Invalid Input

Interests/ Hobbies
Invalid Input

Copyright © 2022 Acuworks Health. All Rights Reserved.

×

Log in