Client Medical History Questionnaire

Our goal is to provide you with the highest level of personalized care. We are committed to helping you achieve optimal health. Please read and fill out the Health Questionnaire as thoroughly as possible. The information you provide is essential for understanding the underlying mechanisms of your symptoms and creating your individualized treatment plan.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Complaints/Concerns

  • Describe Complaints or Problems

  • Example: Headaches severity: 6 better: rest, Advil worse: light, stress
  • Medical History

    Check appropriate box for each condition. Leave blank if non-applicable.

    Gastrointestinal

  • Cardiovascular

  • Metabolic/Endocrine

  • Cancer

  • Genital and Urinary Systems

  • Musculoskeletal

  • Inflammation/Autoimmune

  • Respiratory Disease

  • Skin Disease

  • Neurological/Mood

  • Preventative and Date of Last Test

    Please use the date format MM / YY (i.e. Jan 2016). Leave Blank if non-applicable.

  • Other Diagnostic Procedures

  • Hospitalizations

  • GI History

  • Bowel Habits

  • Patient Birth History

  • Woman's History

    Obstetric History

  • Menstrual History

  • Women's Disorders / Hormonal Imbalances

  • Medication Section

  • Current Medications

  • Previous Medications

  • Nutritional Supplements (Vitamins/Minerals/Herbs/Homopathy)

  • Social History

  • Nutrition History

  • Sweeteners

    Indicate the daily amount of sweeteners used:

  • Smoking

  • Alcohol

    How many drinks per week?

    1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits

  • Other Substances

  • Exercise

  • List any problems that limit activity:

  • Psychosocial

  • Stress/Coping

  • Daily Stressors: Rate on a scale of 1-10 (10 being the most stressful)

  • Scale of 1-10 (10 being most stressful)
  • Scale of 1-10 (10 being most stressful)
  • Scale of 1-10 (10 being most stressful)
  • Scale of 1-10 (10 being most stressful)
  • Scale of 1-10 (10 being most stressful)
  • Sleep / Rest

  • Energy

    How would you rate your energy? (1-10, 10=fantastic)

  • Scale of 1-10 (10=fantastic)
  • Scale of 1-10 (10=fantastic)
  • Scale of 1-10 (10=fantastic)
  • Scale of 1-10 (10=fantastic)
  • Scale of 1-10 (10=fantastic)
  • Roles/Relationships

  • (include name, age and gender)
  • (List total number and names)
  • How have things been going for you?

  • Environmental and Detoxification Assessment

  • Check all that apply
  • Check all that apply
  • Symptom Review

    Please rank all current symptoms or those within the last 6 months.

    Mild: symptoms come and go and you can live with it
    Moderate: symptoms occur 2-3 times per week with frequency that you would like to do something about
    Severe: symptoms occur 4 times or more per week or occurs with regularity on a monthly or cyclical basis

    General

  • Head, Eyes & Ears

  • Musculoskeletal

  • Mood Nerves

  • Eating

  • Digestion

  • Skin Problems

  • Itching Skin

  • Skin, Dryness of

  • Lymph Nodes

  • Nails

  • Respiratory

  • Cardiovascular

  • Urinary

  • Male Reproductive

  • Female Reproductive

  • Dental

  • MSQ - Medical Symptom Toxicity Questionnaire

    Indicate symptoms for the past 30 days. Point Scale:

    0=Never or almost never have symptom
    1=Occasionally have it, effect is not severe
    2=Occasionally have it, effect is severe
    3=Frequently have it, effect is not severe
    4=Frequently have it, effect is severe
  • Head Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Eyes Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Ears Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Nose Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Mouth/Throat Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Skin Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Heart Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Lungs Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Digestive Tract Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Joints/Muscle Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Weight Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Energy/Activity Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Mind Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Emotions Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • Other Section

  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • If you have experienced this symptom in the last 30 days, how would you rank it on a scale of 0-4?
  • This field is for validation purposes and should be left unchanged.